Improving prevention in primary care: Evaluating the sustainability of outreach facilitation

Abstract

Objective: To assess the extent to which advances in preventive care delivery, achieved in primary care practices through outreach facilitation, could be sustained over time after purposefully redirecting the focus of practice physicians and staff away from prevention and toward a new content area in need of improvement-chronic illness management.

Design: Before-and-after study.

Setting: Primary care networks and family health networks in Ontario.

Participants: A volunteer sample of 30 primary care practices recruited from 99 eligible sites.

Intervention: Outreach visits directed at modifying physician behaviour were delivered by trained nurse facilitators using practice-tailored systems strategies. For the first 12 months, the intervention focused on improving delivery of preventive care, after which facilitation of chronic illness management was introduced for another 3 to 9 months.

Main outcome measures: Changes in practices' performance rates for selected preventive maneuvers (according to recommendations of the Canadian Task Force on Preventive Health Care) between baseline and follow-up, conducted 3 to 9 months after the end of the prevention intervention, measured from chart reviews for those maneuvers likely to be recorded and from telephoneinterviews with patients for lifestyle counseling.

Results: Four of the 30 practices dropped out of the study. In the remaining practices, at the postintervention follow-up, there was an increase in the delivery of the appropriate grade A (19.3%, 95% confidence interval [CI] 10.4% to 28.3%) and B (9.3%, 95% CI 5.4% to 13.2%) maneuvers, accompanied by a reduction in inappropriate grade D maneuvers (-15.9%, 95% CI -22.1% to -9.6%), for an absolute improvement of 12% (P < .0001) in the overall preventive care performance, as determined by a chart audit. We found no changes in the provision of lifestyle counseling maneuvers measured from telephone interviews with patients (1.3%, 95% CI 1.0% to 3.7%).

Conclusion: The tailored, multifaceted intervention delivered by nurse facilitators was effective in producing significant improvements in preventive care performance that extended beyond the prevention intervention period.

Figures

Figure 1

Progress during study: Because practices were recruited over time, actual dates of data collection, preventive health care intervention initiation, and implementation of the chronic illness care management distractor activity differed across practices.