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Background: There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders., Methods: The leaders of 8 grants from Agency for Research and Quality for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over 18 months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them., Results: The taxonomy includes 1 domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another 5 domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions., Conclusions: This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between 3 areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research., Competing Interests: Conflict of interest: None., (© Copyright 2021 by the American Board of Family Medicine.)

Background: Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts., Objective: To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context., Design: Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines., Participants: 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs)., Main Measures: Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach., Key Results: Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts., Conclusions: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

Objective: HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation., Methods: A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices., Results: Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager., Conclusions: These attributes may be important determinants of high performance, indicating not only a small practice's capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.

Purpose: Small independent primary care practices (SIPs) often lack the resources to implement system changes. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality, studied the effectiveness of practice facilitation to improve cardiovascular disease- related care in 257 SIPs. We sought to understand SIP clinicians' perspectives on the benefits of practice facilitation., Methods: We conducted in-depth interviews with 19 SIP clinicians enrolled in HealthyHearts NYC. Interviews were transcribed and coded using deductive and inductive approaches. To understand whether the perceived benefits of practice facilitation differ based on the availability of internal staff for quality improvement (QI), we compared themes pertaining to benefits between practices with 3 or fewer office staff vs more than 3 office staff., Results: Clinicians perceived 2 main benefits of practice facilitation. First, facilitators served as a connection to the external health care environment for SIPs, often through teaching and information sharing. Second, facilitators provided electronic health record (EHR)/data expertise, often by teaching functionality and completing technical assistance and tasks. SIPs with more than 3 office staff felt that facilitators provided benefits primarily through teaching, whereas SIPs with 3 or fewer staff felt that facilitators also provided hands-on support. At the intersections of these benefits, there emerged 3 central practice facilitation benefits: (1) creating awareness of quality gaps, (2) connecting practices to information, resources, and strategies, and (3) optimizing the EHR for QI goals., Conclusions: SIP clinicians perceived practice facilitation to be an important resource for connecting their practice to the external health care environment and resources, and helping their practice build QI capacity through teaching, hands-on support, and EHR-driven solutions., (© 2019 Annals of Family Medicine, Inc.)

Purpose: We wanted to describe small, independent primary care practices' performance in meeting the Million Hearts ABCSs (aspirin use, blood pressure control, cholesterol management, and smoking screening and counseling), as well as on a composite measure that captured the extent to which multiple clinical targets are achieved for patients with a history of arteriosclerotic cardiovascular disease (ASCVD). We also explored relationships between practice characteristics and ABCS measures., Methods: We conducted a cross-sectional, bivariate analysis using baseline data from 134 practices in New York City. ABCS data were extracted from practices' electronic health records and aggregated to the site level. Practice characteristics were obtained from surveys of clinicians and staff at each practice., Results: The proportion of at-risk patients meeting clinical goals for each of the ABCS measures was 73.0% for aspirin use, 69.6% for blood pressure, 66.7% for cholesterol management, and 74.2% screened for smoking and counseled. For patients with a history of ASCVD, only 49% were meeting all ABC (aspirin use, blood pressure control, cholesterol management) targets (ie, composite measure). Solo practices were more likely to meet clinical guidelines for aspirin (risk ratio [RR] =1.17, P =.007) and composite (RR=1.29, P = .011) than practices with multiple clinicians., Conclusion: Achieving targets for ABCS measures varied considerably across practices; however, small practices were meeting or exceeding Million Hearts goals (ie, 70% or greater). Practices were less likely to meet consistently clinical targets that apply to patients with a history of ASCVD risk factors. Greater emphasis is needed on providing support for small practices to address the complexity of managing patients with multiple risk factors for primary and secondary ASCVD., Competing Interests: Conflicts of interest: authors report none., (© 2018 Annals of Family Medicine, Inc.)

Patients belonging to some racial, ethnic, and socioeconomic groups are at risk of receiving suboptimal pain management. This study identifies health care provider attitudes, knowledge, and practices regarding the treatment of chronic pain in vulnerable patient populations and assesses whether a certified continuing medical education (CME) intervention can improve knowledge in this area. Survey responses revealed several knowledge gaps, including a lack of knowledge that the undertreatment of pain is more common in minority patients than others. Respondents identified language barriers, miscommunication, fear of medication diversion, and financial barriers as major obstacles to optimal pain management for this patient population. Participants who completed a CME-certified activity on pain management disparities demonstrated increased confidence in caring for disadvantaged patients, but only 1 of 3 knowledge items improved. Understanding clinician factors that underlie suboptimal pain management is necessary to develop effective strategies to overcome disparities and improve quality of care for patients with chronic pain., (© 2013 by the American College of Medical Quality.)

Aims: The timely evidence-based care of type 2 diabetes mellitus (T2DM) is imperative for achieving and maintaining glycemic control, reducing complications, and changing the paradigm of this epidemic. Based largely on results from earlier performance improvement (PI) activities, we conducted a continuing medical education (CME)-certified PI activity to foster improved adherence to guideline recommendations and current evidence for the care of patients with T2DM., Methods: Participants engaged in a 3-stage process of self-assessment, goal setting, and reassessment., Results: A total of 64 clinicians completed the entire PI process, abstracting data from 1600 patient charts before and after a period of self-improvement. After the intervention, clinicians were more likely to assess patients for disease-related complications and provide counseling on proper nutrition, exercise, and smoking cessation. Patients with A1C, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) values above goal (defined as A1C ≥7, BP ≥130/80 mm Hg, and LDL-C >100 g/dL) were more likely to receive treatment modifications compared with baseline clinician performance. Significant changes observed in patient outcomes included improved mean A1C values (baseline 7.5% vs postintervention 7.3%; P = .027), decreased likelihood of BP at or above 130/80 mm Hg (baseline 37% vs postintervention 30%; P < .001), and decreased likelihood of LDL-C above 100 g/dL (baseline 33% vs postintervention, 27%; P < .001)., Conclusions: Significant changes in clinician performance of key quality measures were reported in patients with T2DM after a PI CME activity improved adherence to evidence-based recommendations of care.

Background: Osteoporosis is a widespread but largely preventable disease. Improved adherence to screening and treatment recommendations is needed to reduce fracture and mortality rates. Additionally, clinicians face increasing demands to demonstrate proficient quality patient care aligning with evidence-based standards., Methods: A three-stage, clinician-focused performance improvement (PI) continuing medical education (CME) initiative was developed to enhance clinician awareness and execution of evidence-based standards of osteoporosis care. Clinician performance was evaluated through a retrospective chart analysis of patients at risk or with a diagnosis of osteoporosis., Results: Seventy-five participants reported their patient practices on a total of 1875 patients before and 1875 patients after completing a PI initiative. Significant gains were made in the use of Fracture Risk Assessment Tool (FRAX) (stage A, 26%, n=1769 vs. stage C, 51%, n=1762; p<0.001), assessment of fall risk (stage A, 46%, n=1276 vs. stage C, 89%, n=1190; p<0.001), calcium levels (stage A, 62%, n=1451 vs. stage C, 89%, n=1443; p<0.001), vitamin D levels (stage A, 79%, n=1438 vs. stage C, 93%, n=1439; p<0.001), and medication adherence (stage A, 88%, n=1136 vs. stage C, 96%, n=1106; p<0.001)., Conclusions: Gains in patient screening, treatment, and adherence were associated with an initiative promoting self-evaluation and goal setting. Clinicians must assess their performance to improve patient care and maintain certification. PI CME is a valid, useful educational tool for accomplishing these standards.

Objective: To improve the quality of care for residents of long term care (LTC) facilities who have diabetes by (1) improving glycemic control, (2) increasing comprehensive diabetes management, (3) reducing fragmented care, and (4) empowering patient-care teams to educate patients and families regarding this disease., Design: Based on the Plan-Do-Study-Act principles of effective change, a baseline evaluation of contemporary care for residents with diabetes was conducted through focus-group interviews, a confidence survey, and chart review. Three live educational workshops provided guideline-recommended information addressing educational desires and needs of clinical staff, a tool for improving performance in key areas of need, and an opportunity for care teams to engage in dialogue about advances in diabetes with a national diabetes expert. Reassessment was performed via chart review twice at 3 and 5 months post education. Key lessons and tools for improvements were disseminated to other LTC communities through a CME-certified publication activity and follow-up teleconferences., Setting: Two skilled-nursing LTC communities., Participants: Physicians, administrators, nurses, certified nursing assistants, and nutrition staff., Intervention: Three live continuing education/continuing medical education-certified workshops attended by 83 health care professionals., Measurements: Twenty-five comprehensive clinical indicators of diabetes care and overall health were assessed for all residents with a diabetes diagnosis at baseline (n = 35), 3 months (n = 40), and 5 months (n = 27) post education., Results: The primary objective of improving glycemic control we reached through a statistically significant 18% reduction in the percentage of residents experiencing hypoglycemia from baseline to 3 months post education (31% at baseline, 13% at 3 months, P = .046). Low levels of hypoglycemia (11%) were maintained at 5 months post education. Positive changes in an additional 3 measures of patient health include improved daily blood glucose levels, reduced ranges of HbA1c, and improved low-density lipoprotein cholesterol concentrations. Improvements in 4 measures of clinician performance were also observed, namely comprehensive foot evaluations, referrals to specialists for foot care and eye exams, and improved use of physical activity., Conclusion: Diabetes care, particularly in elder adults, is complex and requires a multidisciplinary approach. Focused quality improvement activities within LTC communities offer care providers the information and tools required to make effective changes that have the ability to promote improved patient care. These efforts must be multidisciplinary and effectively engage all stakeholders., (Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Clinicians are aware of the importance of thromboprophylaxis, and that the application of measures to prevent venous thromboembolism (VTE) occurrence in hospitalized patients must be improved. To enhance clinician execution of appropriate steps to reduce the risk of inpatient VTE, a performance improvement (PI) continuing medical education (CME) initiative consisting of 3 independent tracks for hospitalized patients-patients who are medically ill, patients receiving oncology treatment, and patients undergoing major orthopedic surgery-was designed and implemented. After a baseline chart review of select evidenced-based performance measures for VTE risk stratification and prevention, participants identified ≥ 1 area of personal improvement. Participants then engaged in a period of self-improvement and reassessed their performance with a second chart review. After participating in the PI CME activity, clinician participants in the medically ill track increased their documentation of VTE risk assessments upon patient admission from baseline (56% vs 93%, n = 250; P < 0.001) and their prescription of low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux (72% vs 88%, n = 250; P < 0.001). Orthopedic-track participants were significantly more likely to prescribe 15 to 35 days of VTE prophylaxis after total hip arthroplasty or hip fracture surgery upon patient discharge compared with baseline (51%, n = 123 vs 61%, n = 107; P < 0.001). Oncology-track participants demonstrated a nonsignificant trend for assessing and documenting bleeding risk after participation in the PI CME activity (56% vs 68%, n = 80; P = 0.143). Improvements in evidence-based strategies to reduce the risk of inpatient VTE were associated with PI CME participation. Although areas for improvement remain, increased participant identification and use of prophylactic measures can reduce the risk of VTE in hospitalized patients.

Despite the existence and wide acceptance of guidelines for the treatment of patients with acute coronary syndromes, gaps in patient care still remain. To improve clinical processes of acute coronary syndromes care, a performance improvement (PI) continuing medical education (CME) program, a CME format approved by the American Medical Association, was developed. Clinician participants underwent a 3-stage process: (1) an initial patient chart review for self-assessment purposes, (2) the development and implementation of a personalized PI plan focusing on strategies to enhance processes of care, and (3) a second patient chart review to assess the changes in practice. Although participants provided a high baseline level of guideline-recommended care, there was an improvement in the documentation of the use of risk scores and a trend towards improved treatment times including many participants reaching a door-to-needle time of within 30 minutes. Participants were also more likely to measure cardiac biomarkers and document electrocardiogram performance times. These results demonstrate that PI is a valid and effective means of CME that has the potential to positively affect patient outcomes.

Purpose – The purpose of this paper is to examine the feasibility of collecting standardized, patient reported race and ethnicity (RE) data in hospitals, and to assess the impact on data quality and utility. Design/methodology/approach – Part of a larger evaluation that included a comprehensive assessment. Sites documented RE data collection procedures before and after program implementation. Primary data collected through qualitative interviewing with key respondents in ten hospitals to assess implementation. Nine hospitals provided RE data on the same patients before and after implementation new data collection procedures were implemented to assess impact. Findings – Implementation went smoothly in nine of ten hospitals and had substantial effects on the hospital staff awareness on the potential for disparities within their hospitals. New procedures had minimal impact on characterization of readmitted patients. Practical implications – This study demonstrated that it is feasible for staff in a diverse group of hospitals to implement systematic, internally standardized methods to collect self-reported RE data from patients. Originality/value – Although this study found little impact patients’ demographic characterizations, other benefits included greater awareness of and attention to disparities, uncovering small pockets of minorities, and dramatically increased RE data use in quality improvement efforts. [ABSTRACT FROM AUTHOR]

Introduction: HealthyHearts NYC (HHNYC), a cooperative in the EvidenceNOW initiative, tested the effectiveness of practice facilitation (PF) on the adoption of the Million Hearts ABCS cardiovascular disease evidence-based guidelines (EBG) in small independent practices (SIPs): aspirin in high-risk individuals (A); blood pressure (BP) control and management (B); cholesterol management (C); and screening for tobacco use and, if a smoker, providing cessation services (S). HHNYC also adapted the Million Hearts EBGs to develop two unique measures: 1) a disaggregation of the smoking measure quantifying the proportion of tobacco users who received cessation counseling or a pharmacologic intervention ("smokers counseled"); and 2) the proportion of patients with a history of atherosclerotic cardiovascular disease who met all treatment targets for the A, B, and C outcomes ("ABC composite"). Methods: HHNYC used a cluster randomized stepped-wedge design to test the effect of PF (12 month intervention) on the Million Hearts EBGs in SIPs in NYC. To estimate the impact of the PF intervention, we used Poisson generalized linear mixed-effects models with (1) repeated measures nested within one of 255 SIPs, (2) randomly varying intercepts across SIPs, and (3) an observation-level random effect to address overdispersion. Results: Implementation of the intervention led to an increase in the proportion of smokers counseled (IRR=1.12, 95% CI=1.04-1.19, p=<.001). There were no other statistically significant PF effects. Discussion: SIPs started the intervention with high rates of EBG care—meeting or exceeding Million Hearts goals (i.e. 70% or greater)—which may explain why we did not observe significant improvements in most measures. Indeed, SIPs performed well in the screening part of the smoking measure before PF—the average screening rate during the baseline period across SIPs was 77%—but the increased proportion of smokers counseled suggests room for improvement in this aspect of the smoking measure. We recommend adding the proportion of smokers counseled to other performance measures of EBG care for cardiovascular disease prevention in SIPs. [ABSTRACT FROM AUTHOR]

Introduction: HealthyHearts NYC (HHNYC), a cooperative in the Agency for Healthcare Research and Quality EvidenceNOW initiative, tested the effect of practice facilitation (PF) on practice-level blood pressure (BP) control in 255 small independent practices (SIPs). Few studies of interventions to improve BP control have considered the implications of seasonal variation when analyzing BP outcomes Methods: HHNYC used a cluster randomized stepped-wedge design to test the effect of PF (12 month intervention) on the proportion of patients meeting the Million Hearts BP target (≥70% BP controlled) among SIPs in NYC. BP data were extracted from SIPs' electronic health records. We used Poisson generalized linear mixed-effects models, with repeated measures nested within one of 255 SIPs and randomly varying intercepts across SIPs to assess the intervention effect. We did a second analysis that adapted the Poisson model to include (1) an observation-level random effect to address overdispersion (more variance in the counts than expected for a Poisson distribution) and (2) two terms in the fixed-effects portion of the model to separately contrast quarter one and then quarter three with quarters two and four, to address BP seasonality. Results: The first model found a significant negative association between PF and BP control (i.e., BP control declined) (IRR=0.98, 95% CI=0.96-0.99, p=<.001). In the full model (i.e., addressing seasonal changes) PF had no effect on BP control (IRR = 0.99, 95% CI=0.97-1.0, p=.19). The rate of BP control was significantly lower in quarter one (IRR = 0.97; 95% CI: 0.96-0.98, p<.01) and higher in quarter three (IRR=1.02; 95% CI: 1.01-1.03, p<.01) when compared with quarters two and four. Discussion: Many SIPs already met or exceeded national estimates of BP control and the Million Hearts BP performance target before the intervention, perhaps challenging further improvement without additional patient level intervention components that were not part of HHNYC. BP seasonality has strong study design implications. For stepped-wedge trials, sufficient waves are required to ensure the expected timing of intervention impact is spread evenly over quarters so the seasonality and any intervention impact can be more easily disentangled. [ABSTRACT FROM AUTHOR]