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Background: A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly. Methods: A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg): (1) clinic-based care using best practices and face-to-face visits with physicians and medical assistants; and (2) telehealth care using best practices and adding home BP telemonitoring with home-based care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in patient-reported outcomes over 6 months. Results: Participants (N=3071 in 21 primary care clinics) were on average 60 years old, 47% male, and 19% Black. Protocol-specified follow-up within 6 weeks was 32% in clinic-based care and 27% in telehealth care. BP decreased significantly during 12 months of follow-up in both groups, from 157/92 to 139/82 mm Hg in clinic-based care patients (adjusted mean difference −18/−10 mm Hg) and 157/91 to 139/81 mm Hg in telehealth care patients (adjusted mean difference −19/−10 mm Hg), with no significant difference in systolic BP change between groups (−0.8 mm Hg [95% CI, −2.84 to 1.32]). Telehealth care patients were significantly more likely than clinic-based care patients to report frequent home BP measurement, rate their BP care highly, and report that BP care visits were convenient. Conclusions: Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02996565.

OBJECTIVE Identify the improvement in diabetes performance measures and population-based clinical outcomes resulting from changes in care management processes (CMP) in primary care practices over 3 years. RESEARCH DESIGN AND METHODS This repeated cross-sectional study tracked clinical performance measures for all diabetes patients seen in a cohort of 330 primary care practices in 2017 and 2019. Unit of analysis was patient-year with practice-level CMP exposures. Causal inference is based on dynamic changes in individual CMPs between years by practice. We used the Bayesian method to simultaneously estimate a five-outcome model: A1c, systolic and diastolic blood pressure, guideline-based statin use, and Optimal Diabetes Care (ODC). We control for unobserved time-invariant practice characteristics and secular change. We modeled correlation of errors across outcomes. Statistical significance was identified using 99% Bayesian credible intervals (analogous to P < 0.01). RESULTS Implementation of 18 of 62 CMPs was associated with statistically significant improvements in patient outcomes. Together, these resulted in 12.1% more patients meeting ODC performance measures. Different CMPs affected different outcomes. Three CMPs accounted for 47% of the total ODC improvement, 68% of A1c decrease, 21% of SBP reduction, and 55% of statin use increase: 1) systems for identifying and reminding patients due for testing, 2) after-visit follow-up by a nonclinician, and 3) guideline-based clinician reminders for preventive services during a clinic visit. CONCLUSIONS Effective quality improvement in primary care focuses on practice redesign that clearly improves diabetes outcomes. Tailoring CMP adoption in primary care provides effective improvement in ODC performance through focused changes in diabetes outcomes.

Primary care practices in underserved and/or rural areas have limited access to mental health specialty resources for their patients. Telemedicine can help address this issue, but little is known about how patients and clinicians experience telemental health care.This pragmatic randomized effectiveness trial compared telepsychiatry collaborative care, where telepsychiatrists provided consultation to primary care teams, to a referral approach, where telepsychiatrists and telepsychologists assumed responsibility for treatment. Twelve Federally Qualified Health Centers in rural and/or underserved areas in 3 states participated.Patients and clinicians reported that both interventions alleviated barriers to accessing mental health care, provided quality treatment, and offered improvements over usual care. Telepsychiatry collaborative care was identified as better for patients with difficulty developing trust with new providers. This approach also required more primary care involvement than referral care, creating more opportunities for clinician learning related to mental health diagnosis and treatment. The referral approach was identified as better suited for patients with higher complexity or desiring specific psychotherapies.Both approaches addressed patient needs and provided access to specialty mental health care. Each approach better aligned with different patients' needs, suggesting that having both approaches available to practices is optimal for supporting patient-centered care.

BACKGROUND: Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives. OBJECTIVE: Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation. STUDY DESIGN: We used an iterative mixed-methods design. PARTICIPANTS, APPROACH, AND MEASURES: We collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation. KEY RESULTS: In the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: − 2.83, p

PURPOSE: To learn whether the COVID-19 pandemic’s disruptions and associated reduced health outcomes for people with chronic conditions might have been caused by a decrease in care management processes (CMPs) in primary care clinics METHODS: Longitudinal cohort design with repeated survey-based measures of CMPs from 2017, 2019, and 2021 in 269 primary care clinics in Minnesota. RESULTS: There were only small differences in organizational characteristics and no differences in overall CMPs between the 269 clinics analyzed and the 287 that only completed surveys in 1 or 2 years. Overall CMP scores rose by similar amounts (1.6% and 2.1%) from 2017 to 2019 and from 2019 to 2021. In 2021, CMP scores were lower in small medical groups than in large medical groups in 2017 (66.1% vs 78.5%, P

Background Hypertension control has been decreasing recently. We compared the experience and attitudes toward care between patients with uncontrolled hypertension who are more and less satisfied with that care to identify ways to improve their care. Methods Baseline survey of 3072 patients with diagnosed hypertension and repeated blood pressure measurements at or above 150/95 mmHg during clinic appointments at 21 primary care clinics of a large Midwestern multi-specialty medical group. Survey questions were about previous hypertension care satisfaction, the degree to which that care was patient-centered, their feelings of self-confidence and treatment burden in managing hypertension, and medication side effects. Results A total of 1697 patients completed surveys (response rate = 55%). Of the 1697 patients, the 24% who were most dissatisfied (scored 0 to 5 on a 0 to 10 scale of satisfaction) significantly differed from those most satisfied (scored 9 to 10) on all demographic and clinical characteristics as well as on every measure of care experience and health status. After adjusting for those characteristics, reports of patient-centered care, self-confidence, stopping the medication because of side effects, and the burdensomeness of treatment were all significantly worse (P Conclusions Many patients with uncontrolled hypertension are dissatisfied with their care, but that is associated with different problems for different people. Identifying and attending to these problems may provide opportunities to help them achieve better control.

Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders.The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes.Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens.Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.

Patient-reported outcome measures (PROMs), increasingly used for research and quality measurement, are lauded for their potential to improve patient-centered care, both through aggregate reporting and when integrated into clinical practice. However, there are few published studies of the resultant use of PROMs in clinical practice. This case study describes the implementation and use of PROMS in a Midwestern multispecialty medical group orthopedic practice among patients undergoing total knee and hip surgery. Specifically, rates of PROMs use by care teams are tracked over time once made available in the electronic health record. During this time, the orthopedics department achieved a patient PROMS survey response rate of 68% at baseline, 58% 3 months post-surgery, and 55% 12 months post-surgery. However, these data were only accessed by the care teams for fewer than 1% of associated clinical encounters. This suggests that making PROMs available for care team review in the electronic health record, even when coupled with relatively high response rates from patients and departmental leadership support is not enough to encourage integration of PROMs into clinical care for patients. Additional effort is required to identify barriers to PROMs use in clinical care and to test methods to enhance use.

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.

PURPOSE The aim of this study was to determine what strategies and factors are most important for high performance in the primary care of patients with diabetes. METHODS We performed a mixed-methods, cross-sectional, observational analysis of interviews and characteristics of primary care clinics in Minnesota and bordering areas. We compared strategies, facilitators, and barriers identified by 31 leaders of 17 clinics in high-, middle-, and low-performance quartiles on a standardized composite measure of diabetes outcomes for 416 of 586 primary care clinics. Semistructured interview data were combined with quantitative data regarding clinic performance and a survey of the presence of care management processes. RESULTS The interview analysis identified 10 themes providing unique insights into the factors and strategies characterizing the 3 performance groups. The main difference was the degree to which top-performing clinics used patient data to guide proactive and outreach methods to intensify treatment and monitor effect. Top clinics also appeared to view visit-based care management processes as necessary but insufficient, whereas all respondents regarded being part of a large system as mostly helpful. CONCLUSIONS Top-performing clinic approaches to diabetes care differ from lower-performing clinics primarily by emphasizing data-driven proactive outreach to patients to intensify treatment. Although confirmatory studies are needed, clinical leaders should consider the value of this paradigm shift in approach to care.

OBJECTIVE: To identify the impact of changes surrounding certification as a patient‐centered medical home (PCMH) on outcomes for patients with diabetes. STUDY SETTING: Minnesota legislation established mandatory quality reporting for patients with diabetes and statewide standards for certification as a PCMH. Patient‐level quality reporting data (2008‐2018) were used to study the impact of transition to a PCMH. STUDY DESIGN: Achievement of Minnesota's optimal diabetes care standard—in aggregate and by component—was modeled for adult patients with Type 1 or Type 2 diabetes as a function of time relative to the year the patient's primary care practice achieved PCMH certification. Patients from uncertified practices were used to control for general trend. Practice‐level random effects captured time‐invariant characteristics of practices and the practices’ average patient. DATA COLLECTION: Electronic health record data were submitted by 695 Minnesota practices capturing components of the quality standard: blood sugar control, cholesterol control, blood pressure control, nonsmoking status, and use of aspirin. PRINCIPAL FINDINGS: The first cohort of practices achieving PCMH certification (July 2010‐June 2014) showed statistically insignificant changes in optimal care. The next cohort of practices (July 2014‐June 2018) achieved larger, clinically meaningful increases in quality of care during the time prior to and following certification. Specifically, this second cohort of practices was estimated to achieve a 12.8 percentage‐point improvement (P

ImportanceComputed tomography (CT) radiation doses vary across institutions and are often higher than needed.ObjectiveTo assess the effectiveness of 2 interventions to reduce radiation doses in patients undergoing CT.Design, Setting, and ParticipantsThis randomized clinical trial included 864 080 adults older than 18 years who underwent CT of the abdomen, chest, combined abdomen and chest, or head at 100 facilities in 6 countries from November 1, 2015, to September 21, 2017. Data analysis was performed from October 4, 2017, to December 14, 2018.InterventionsImaging facilities received audit feedback alone comparing radiation-dose metrics with those of other facilities followed by the multicomponent intervention, including audit feedback with targeted suggestions, a 7-week quality improvement collaborative, and best-practice sharing. Facilities were randomly allocated to the time crossing from usual care to the intervention.Main Outcomes and MeasuresPrimary outcomes were the proportion of high-dose CT scans and mean effective dose at the facility level. Secondary outcomes were organ doses. Outcomes after interventions were compared with those before interventions using hierarchical generalized linear models adjusting for temporal trends and patient characteristics.ResultsAcross 100 facilities, 864 080 adults underwent 1 156 657 CT scans. The multicomponent intervention significantly reduced proportions of high-dose CT scans, measured using effective dose. Absolute changes in proportions of high-dose scans were 1.1% to 7.9%, with percentage reductions in the proportion of high-dose scans of 4% to 30% (abdomen: odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P P = .03; combined abdomen and chest: OR, 0.49; 95% CI, 0.41-0.59; P P P P P Conclusions and RelevanceFor imaging facilities, detailed feedback on CT radiation dose combined with actionable suggestions and quality improvement education significantly reduced doses, particularly organ doses. Effects of audit feedback alone were modest.Trial RegistrationClinicalTrials.gov Identifier: NCT03000751

PURPOSE: The purpose of this study was to assess whether primary care practices certified as medical homes differ in having the practice systems required for that designation and in attaining favorable outcomes for their patients with diabetes, and whether those systems are associated with better diabetes outcomes. METHODS: We undertook a cross-sectional observational study, Understanding Infrastructure Transformation Effects on Diabetes (UNITED), of 586 Minnesota adult primary care practices, comparing those that were certified vs uncertified as medical homes in 2017, with analyses supplemented by previously published studies of these practices. We collected survey information about the presence of medical home practice systems for diabetes care and obtained 6 standardized measures of diabetes care collected yearly from all Minnesota practices. RESULTS: Of 416 practices completing questionnaires (71% of all practices, 92% of participating practices), 394 had data on diabetes care measures. Uncertified practices (39%) were more likely than certified practices to be rural, but their patient populations were similar. Certified practices had more medical home practice systems (79.2% vs 74.9%, P =.01) and were more likely to meet a composite measure of optimal diabetes care (46.8% vs 43.2%, P

To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care.Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720).Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours,Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly promoted for use in routine orthopaedic care with the expectation that if they are made available during encounters, they will be incorporated into clinical practice. We investigated an initiative in which PROMs were systematically collected and provided via the electronic health record but were infrequently used. QUESTIONS/PURPOSES: In a qualitative study, we asked: (1) Why are PROM results not being used in clinical care when they are available to surgeons? (2) What aspects of PROMs are seen as useful for clinical care? (3) How are PROMs generally perceived by surgeons and orthopaedic leaders? METHODS: A cross-sectional qualitative study was conducted in a single health system in an urban setting using semistructured interviews with a purposive sample of orthopaedic surgeons and leaders who would have substantial knowledge of and experience with the organization’s PROM system, which was embedded in the electronic health record and developed for use in clinical care but was not being used. We included surgeons whose practices consisted of at least 90% patients with osteoarthritis, including surgical and nonsurgical management, and thus their patients would be completing PROMs surveys, or surgeons who were leaders in one of the three orthopaedic divisions in the health plan. The senior research manager for orthopaedics identified 14 potential participants meeting these criteria, 11 of whom agreed to study participation. Participants included nine surgeons and two orthopaedic leaders; the majority were men, with a median of 13 years of clinical practice. Study interviews were conducted by an experienced interviewer not known to participants, in private conference rooms in the healthcare setting, and a median (range) of 27 minutes (16 to 40) in length. A content analysis approach was employed for data analysis, with thematic inductive saturation reached in the analysis and attention to trustworthiness and rigor during the analytic process. RESULTS: Interviewees reported that PROM scores are not being used in patient clinical care because of logistical barriers, such as access and display issues and the time required, and perceptual barriers, such as concerns about patient understanding and the validity and reliability of measures. Surgeons preferred talking with patients about the personal outcomes patients had identified as important; most patients preferred to assess progress toward their own goals than PROMs scores for other people. Surgeons also identified changes that could facilitate PROM use and reduce barriers in clinical care, including pushing PROM scores to physicians’ inboxes, developing inserts for physician notes, using easy-to-understand graphical displays, and engaging patients about PROMs earlier in the care process. Participants all agreed that PROMs in aggregate use are valuable for the organization, department, and individual surgeons, but individual patient scores are not. CONCLUSION: Despite the availability of PROMs, there are important barriers to incorporating and using PROMs in clinical care. Providing access to PROM scores without clearly understanding how and why surgeons may consider using or incorporating them into their clinical practice can result in expensive and underused systems that add little value for the clinician, patient, or organization. CLINICAL RELEVANCE: Involving front-line orthopaedic surgeons and leaders in shaping the design and structure of PROM systems is important for use in clinical care, but these interviewees seemed to see aggregate data as more valuable than individual patient scores.

Background Although shared decision-making (SDM) has knowledge and satisfaction benefits for patients and is promising, we lack data demonstrating that SDM is associated with better patient-reported functional outcomes. Such data would support the integration and prioritization of SDM into all aspects of orthopaedic care. Questions/purposes (1) Is a measure of SDM before total joint arthroplasty associated with better patient-reported outcome measures (PROMs) 1 year postoperatively? (2) What is the relationship between the measure of SDM and two measures of patient experience (patient rating of the provider and patient likelihood of recommending the provider) at 1 year postoperatively? Methods In this observational longitudinal survey-based study, patients receiving an initial THA or TKA from a large, multispecialty medical group in the Midwestern United States were surveyed after they were scheduled for surgery and again at 12 months after their procedure. The three-item collaboRATE measure of SDM was added to existing patient surveys of PROMs. However, the surgeons and their department had no organized approach to SDM during this time. The surveys also included the Oxford knee or hip score and two validated measures of patient experience (patient rating of the provider and whether a patient would recommend the provider). Of the 2779 eligible primary joint arthroplasties that occurred from April 23, 2018 to May 1, 2019, 48% (1334 procedures; 859 TKAs and 485 THAs) of the patients responded to both the preoperative and 12-month postoperative surveys. Most of the patients who were included in the analytic sample were white (93%; 1255 of 1344), with only 3% (37) using Medicaid benefits at the time of surgery. Differences between responders and nonresponders were present and explored in an analysis. Patient responses were analyzed in regression models to estimate the association between preoperative collaboRATE scores and the Oxford knee or hip scores, and patient experience measures 12 months postoperatively. Results There was a moderate, positive association between preoperative collaboRATE scores and the Oxford scores at 12 months, after adjustment for potential confounders such as patient age and preoperative functional score (β = 0.58; 95% CI 0.14-1.02; p = 0.01). Similarly, patients with preoperative collaboRATE scores had marginally higher patient experience scores at 12 months postoperatively (β = 0.14; 95% CI 0.05-0.24; p = 0.003) and were more likely to recommend their surgeon (OR 1.43; 95% CI 1.11-1.84; p = 0.005). The patient experience measures were also modestly correlated with collaboRATE scores in cross-sectional associations, both preoperatively and at 12 months postoperatively (0.29 ≤ r ≤ 0.54; p Conclusion The association between preoperative collaboRATE scores and Oxford hip or knee scores suggests that SDM could be one tool to encourage better outcomes. Although previous studies have shown that SDM can improve patient experience, the lack of a strong correlation in our study suggests that PROMs and experience measures are separate domains, at least partly. Improving preoperative SDM between the surgeon and patient might help improve surgical outcomes for patients undergoing TKA and THA. Level of evidence Level II, therapeutic study.

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.

Although previous work suggests that high performing practices focus on proactive patient outreach, the specific care management processes (CMP) that improve diabetes outcomes remain unclear. We evaluated 60 CMP from a state-wide practice survey in 2017 and 2019. Previously validated, the survey included 586 practices in 2017 (71% response, N=415) and 627 practices in 2019 (71% response, N= 445). Electronic health record data for A1c, blood pressure (BP), and lipid management were extracted for all patients with type 1 or type 2 diabetes in the practices. The longitudinal data set included 395 practices providing care to 204,745 patients. We used a longitudinal Bayesian model to correlate CMPs with A1c, systolic/diastolic BP, and probability of taking a statin. Patient outcomes were controlled for age, sex, diabetes type, insurance, comorbidity, community-level race-ethnicity, wealth, education, and income. Practices were controlled for rurality, size, FQHC status, system size, and practice-level random effects. Significance was reduced to Disclosure K. A. Peterson: Board Member; Self; Treatment.com International Inc. C. Carlin: None. L. Solberg: None. M. Eder: None. Funding National Institutes of Health (R18DK110732)

Disruptions in primary care practices, like ownership change, clinician turnover, and electronic health record system implementation, can stall quality improvement (QI) efforts. However, little is known about the relationship between these disruptions and practice participation in facilitated QI.We explore this relationship using data collected from EvidenceNOW in a mixed-methods convergent design. EvidenceNOW was a large-scale facilitation-based QI initiative in small and medium primary care practices. Data included practice surveys, facilitator time logs, site visit field notes, and interviews with facilitators and practices. Using multivariate regression, we examined associations between disruptions during interventions and practice participation in facilitation, measured by in-person facilitator hours in 987 practices. We analyzed qualitative data on 40 practices that described disruptions. Qualitative and quantitative teams iterated analyses based on each other's emergent findings.Many practices (51%) reported experiencing 1 or more disruptions during the 3- to 15-month interventions. Loss of clinicians (31.6%) was most prevalent. In adjusted analyses, disruptions were not significantly associated with participation in facilitation. Qualitative data revealed that practices that continued active participation were motivated, had some QI infrastructure, and found value in working with their facilitators. Facilitators enabled practice participation by doing EHR-related work for practices, adapting work for available staff, and helping address needs beyond the explicit aims of EvidenceNOW.Disruptions are prevalent in primary care, but practices can continue participating in QI interventions, particularly when supported by a facilitator. Facilitators may benefit from additional training in approaches for helping practices attenuate the effects of disruptions and adapting strategies to help interventions work to continue building QI capacity.

Background: Addressing the opioid epidemic would benefit from primary care clinicians identifying and managing opioid use disorder (OUD) during routine clinical encounters, but current rates are low. Clinical decision support (CDS) systems are a promising way to facilitate such interactions, but will clinicians use them? Methods: We iteratively conducted semi-structured interviews with 8 purposively sampled primary care clinicians participating in a pilot OUD-CDS study to identify attitudes toward discussing OUD and preferences for support in doing so. Five of them had used a pilot version of the CDS for 6 months, while the others were in comparison clinics. Interviews were recorded, transcribed, and analyzed by a multi-disciplinary group of experienced researchers, using an editing organizing style where the analysts independently highlighted relevant text and then discussed to reach a consensus on themes. Results: We identified five themes: 1. Primary care is the right place to address OUD. 2. Both clinician-patient and clinician-clinician relationships affect how and whether clinicians address OUD in a particular patient encounter. 3. The main challenges are limited time and competing priorities for these complex patients. 4. Although a CDS for OUD could be very helpful, it must meet different needs for different clinicians and clinical situations and be simple to use. 5. For optimal benefit, the CDS needs to be complemented by supportive organizational policies and systems as well as local clinician encouragement. Conclusions: With the right design and a supportive organization, these primary care clinicians believe a CDS could help them regularly identify and address OUD among their patients as long as it incorporates their concerns about relationships, competing priorities, patient complexity, and user simplicity.

BACKGROUND: The use of diagnostic imaging with computed tomography (CT) has risen significantly, increasing cumulative life-time exposure to ionizing radiation for patients and raising concerns about increased cancer risk. Lowering the doses would reduce concerns about associated cancer risks. PURPOSE: To determine organizational leaders’ perceptions of barriers to optimizing radiation dose in computed tomography (CT). MATERIALS AND METHODS: An observational study using semi-structured interviews conducted with 26 organizational leaders from 19 health care systems in the United States, Europe, and Japan. Interviews focused on approaches the organizations used to optimize radiation dose and barriers encountered. Data were analyzed using a directed content analysis approach. RESULTS: Analysis identified six primary barriers to dose optimization: 1) resistance to change, 2) limited time and resources, 3) complex organizational structure, 4) lack of leadership support, 5) variations in CT equipment, and 6) variability in CT protocols. CONCLUSION: Barriers to optimizing CT dose across diverse health care organizations were described by organizational leaders tasked with implementing and improving CT imaging. They identified six consistent themes that reflected barriers to optimizing radiation dose at the organizational level. These barriers impeded efforts by health care organizations to optimize radiation doses to patients from CT imaging. Identifying barriers early in any improvement process is an important first step in making meaningful and sustained change.

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.

INTRODUCTION Limited quantitative information exists about the patient and surgeon factors driving variation in patient-reported outcome measure (PROM) scores, limiting the use of these data in understanding and improving quality. The overall goal of this study was to learn how to adjust PROM scores to enable both individual and group quality improvement. METHODS Observational study in which preoperative Oxford Knee Score (OKS) and Patient Reported Outcomes Measurement System (PROMIS)-10 measures were prospectively obtained through patient survey from 1,173 of 1,435 possible patients before total knee arthroplasty and from 810 of the 1,173 patients at 12 months postoperatively (response rates = 81.7% and 69.0%). Regression analyses identified the relative contribution of patient and surgeon risk factors to OKS change from baseline to 12 months. Variation in patient scores and surgeon performance was described and quantified. Adjusted outcomes were used to calculate an observed and expected score for each surgeon. RESULTS (1) Moderate variation was observed in pre-/post-OKS change among the surgeons (n = 16, mean change = 15.5 ± 2.2, range = 12.1-21.1). Forty-five percent of the variance in OKS change was explained by the factors included in our model. (2) Patient preoperative OKS and PROMIS physical score, race, and BMI were markedly associated with change in OKS, but other patient factors, surgeon volume, and years of experience were not. (3) Eight surgeons had observed scores greater than expected after adjustment, providing an opportunity to learn what strategies were associated with better outcomes. DISCUSSION Traditional age/sex adjustment of patient mix would have had no effect on mean PROM scores by surgeon. An adjustment model that includes the factors found to be markedly associated with outcomes will allow care systems to identify individual surgeon care management strategies potentially important for improving patient outcomes.

Introduction: Patient ratings of their experience of care are part of the “Triple Aim”. Improvements are highly valued by health care organizations, but are hard to achieve. Hypothesis: We tested the effect of a telehealth intervention on satisfaction with hypertension care. Methods: Hyperlink 3 is an ongoing pragmatic cluster-randomized trial in 3072 patients with uncontrolled hypertension in 21 primary care clinics in HealthPartners, an integrated health system in Minnesota and Wisconsin. Clinics were randomized to Clinic-based Care (CC, 9 clinics, 1648 patients) or Telehealth Care (TC, 12 clinics, 1424 patients). CC patients received guideline-based hypertension care in face-to-face visits. TC patients were additionally offered home blood pressure (BP) telemonitoring with pharmacist care management. Patients were surveyed at baseline and after 6 months of study enrollment and asked to rate their hypertension care in the previous 6 months on a scale of 0-10. We compared change in the proportion of patients rating their care at the highest level (9 or 10). Results: In the TC group, about 37% of patients attended an intake pharmacist visit and 434 (30%) participated in home BP telemonitoring. Baseline surveys were completed by 1719 (56%) of patients at baseline (goal 50% completion) and 1301 (76%) of those completing the baseline survey completed the 6 month survey (goal 75% completion). Baseline survey respondents’ mean age was 62 y (non-respondents 58 y), 46% were men (non-respondents 48%), 19% were black (non-respondents 20%), and mean BP was 164/93 mm Hg (non-respondents 164/95 mm Hg.) Nearly all patients (over 90%) took antihypertensive medications (median 2). Hypertension care ratings of 9 or 10 were 27.9% at baseline and 30.2% at 6 months in CC, compared with 29.0% at baseline and 39.5% at 6 months in TC. The odds ratio (OR) for change over time in 9 or 10 ratings was 1.11 (95% CI 0.87 - 1.42) in CC, and 1.61 (95% CI 1.26 - 2.07) in TC. The OR for change in 9 or 10 ratings over time in TC vs CC was 1.45 (95% CI 1.03 - 2.06). Conclusions: Home BP telemonitoring with pharmacist care management increased the proportion of patients who highly rated their experience of hypertension care, even though only a minority of the TC patients received the intervention.

Introduction: Telehealth and remote monitoring have become critical to patient access to care during the COVID-19 pandemic. We measured the effect of a telehealth care intervention on frequency, sharing methods, and clinical usage of home blood pressure (BP) measurements. Methods: Hyperlink 3 is an ongoing pragmatic cluster-randomized trial in 3072 patients with uncontrolled hypertension in 21 primary care clinics in an integrated health system. Clinics were randomized to Clinic-based Care (CC, 9 clinics, 1648 patients) or Telehealth Care (TC, 12 clinics, 1424 patients). TC patients were offered home BP telemonitoring with pharmacist care management. Patients were surveyed at baseline (Nov 2017 - Apr 2019) and after 6 mo of study enrollment. Results: In the TC group, about 37% of patients attended an intake pharmacist visit and 434 (30%) participated in home BP telemonitoring. Baseline surveys were completed by 1719 (56%) of patients at baseline (goal 50%) and 1301 (76%) of those completing the baseline survey completed the 6 mo survey (goal 75%). Baseline survey respondents' mean age was 62, 46% were men, 19% were black, and mean BP was 164/93 mm Hg. Nearly all patients (>90%) took antihypertensive medications (median 2). The odds ratio (OR) for change in measuring BP > 2 times/week vs. less often was 0.97 (95% CI 0.87 - 1.42) in CC, and 2.01 (95% CI 1.56 - 2.59) in TC. The OR for change in frequent measurement in TC vs CC was 2.08 (95% CI 1.45 - 2.97). Conclusions: A telehealth care intervention markedly increased the frequency of home BP self- monitoring, electronic data sharing, and data-driven BP medication changes, even though only a minority of TC patients received the intervention.

Purpose of Review This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH. Recent Findings Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. Summary The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.

PurposeThe aim of this study was to identify organizational factors and quality improvement strategies associated with lower radiation doses from abdominal CT.MethodsCross-sectional survey was administered to radiology leaders, along with simultaneous measurement of CT radiation dose among 19 health care organizations with 100 imaging centers throughout the United States, Europe, and Japan, using a common dose management software system. After adjusting for patient age, gender, and size, quality improvement strategies were tested for association with mean abdominal CT radiation dose and the odds of a high-dose examination.ResultsCompleted surveys were received from 90 imaging centers (90%), and 182,415 abdominal CT scans were collected during the study period. Radiation doses varied considerably across organizations and centers. Univariate analyses identified eight strategies and systems that were significantly associated with lower average doses or lower frequency of high doses for abdominal CT examinations: tracking patient safety measures, assessing the impact of CT changes, identifying areas for improvement, setting specific goals, organizing improvement teams, tailoring decisions to sites, testing process changes before full implementation, and standardizing workflow. These processes were associated with an 18% to 37% reduction in high-dose examinations (P < .001-.03). In multivariate analysis, having a tracking system for patient safety measures, supportive radiology leaders, and obtaining clear images were associated with a 47% reduction in high-dose examinations.ConclusionsThis documentation of the relation between quality improvement strategies and radiation exposure from CT examinations has identified important information for others interested in reducing the radiation exposure of their patients.

Background: Care management processes are meant to improve care quality, but there is little information about their effectiveness in socioeconomically disadvantaged individuals. This study was aimed to test if systematic care management processes are as effective in controlling diabetes among Medicaid as in non-Medicaid patients. Methods: This cross-sectional study used standardized performance measures (glycemic control, BP control, statin drug use, aspirin use, smoking cessation) matched to a 2017- clinic survey on the use of diabetes-related care management processes (62 items in Physician Practice Connections-Research Survey). A mixed effect multi-level regression model with fixed clinic- and patient-level independent variables and random clinic-level intercepts was used to test the association between clinic use of care management processes (index of 0-100%) and glycemic control of glycated hemoglobin (A1C) level while adjusting for patient covariates (age, sex, comorbid conditions, diabetes type 1 or 2, residence rurality) and clinic covariates (PCMH certification, medical group size, federally qualified health center). Results: The overall mean index of care-management processes usage was 86% (IQR of 76-97%). Every 10% increase in the use of care management processes was associated with a decrease of 0.57 in A1C (p Conclusions: Clinic utilization of PCMH care management processes had a larger effect on diabetes control for patients on Medicaid than for other patients. Improving and implementing these processes may be an important strategy for reducing disparities in diabetes outcomes. Disclosure H.N. Fu: None. J. Wolfson: None. L. Solberg: None. M. Grey: None. K.A. Peterson: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R18DK110732)

Background: Diabetes care quality has changed little over the past 12 years. To learn what strategies and factors seem most important for improvement, we conducted a mixed method analysis of clinic interviews and characteristics of clinics that are in the high, middle, and low quartiles on a composite measure for diabetes. Method: We interviewed 31 leaders from 17 primary care clinics selected from the 416 that agreed to participate in a larger observational study of diabetes performance improvement. Semi-structured interviews on barriers and facilitators of diabetes care were recorded, transcribed, and analyzed for both comparison among clinics at different levels of performance on the outcome measure. We combined interview data with quantitative data about clinic performance on a standardized composite measure of diabetes outcomes and a survey of the presence of care management processes. Results: Interview analysis identified 10 themes that provided unique insights into the factors and strategies that were associated with differences in performance level. The main difference among them was the degree to which top performing clinics used patient data to guide proactive and outreach methods to intensify treatment and monitor impact. Top clinics also reported fewer barriers and more facilitators than lower ranked ones, while all recognized key help from the larger organizations of which most were a part. Conclusions: Top performing clinics’ approach to diabetes care differs from lower performing clinics focusing on proactive care occurring outside of the traditional practice setting. Although confirmatory studies are needed for these preliminary findings, clinical leaders might benefit by considering the value of replicating these differences. Disclosure L. Solberg: None. K.A. Peterson: None. H.N. Fu: None. M. Eder: None. R. Jacobsen: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R18DK110732)

Purpose: Patient-reported outcome measures (PROMs) are increasingly used in clinical care, but there have been few studies of what patients identify as the most important outcomes. Methods: Semi-structured interviews were conducted with 65 patients undergoing hip or knee replacement, spinal discectomy/laminotomy, or a spinal fusion. Interviews focused on outcomes patients identified as important, perceived usefulness of standardized PROMs measures, and contextual situations important to their care. Data were analyzed using a directed content analysis approach. Results: Patients identified desired outcomes that were unique and important to them. Their preferred outcomes focused in the areas of freedom from pain, getting back to their normal life, and returning to an active lifestyle. Patients cared more about their individual preferred outcomes, which had more meaning for them, than a standardized PROM score. Patients also identified particular contextual situations that their care team was assumed to know about but that may not have been known. Conclusions: Patients identify specific preferred outcomes from these surgical procedures that are important and meaningful to them and that frame whether they see their surgery as a success. They also identified personal factors that they assume their surgeons know about, which affect their care and recovery. These findings underscore the importance of engaging patients in discussions about their preferences and contextual factors both prior to and after surgery.

BACKGROUND: Having depression and living in a rural environment have separately been associated with poor diabetes outcomes, but there little is known about the interaction between the 2 risk factors. This study investigates the association of depression and rurality with glycemic control in adults, as well as their interaction. METHODS: This is a repeated cross-sectional study with data collected from 2010 to 2017 (n = 1,697,173 patient-year observations), comprising a near-complete census of patients with diabetes in Minnesota. The outcome of interest was glycemic control defined as hemoglobin A1c under 8%. We used a logit model with clinic-level random effects to predict glycemic control as a function of depression, patient rurality, and their interaction, adjusted for differences in observed characteristics of the patient, clinic, and patient’s neighborhood. RESULTS: Having depression was associated with lower probability of achieving glycemic control (P < .001). Although rurality alone had no association with glycemic control, significant interactions existed between depression and rurality. Living in a small rural town mitigated the negative association between depression and glycemic control (P < .001). CONCLUSION: Although patients with depression had poorer glycemic control, living in a small rural town reduced the negative association between depression and glycemic control.

Background: Collaborative care models have been shown to improve mental and physical health, but their effectiveness varies. Implementation science frameworks identify measures at the structural (eg, sociocultural context, public policies), organizational, provider, innovation, and patient levels that may facilitate or impede collaborative care effectiveness. Objective: To describe commonalities and variation in multilevel measures associated with the implementation of Care of Mental, Physical, and Substance-Use Syndromes (COMPASS), a large-scale collaborative care intervention for depression, diabetes, and cardiovascular disease. Design: Qualitative study using semistructured descriptive data obtained from annual site visit reports and supplemental site surveys. Participants: COMPASS care teams from 8 health care systems serving 3854 patients with active depression and poorly controlled diabetes and/or cardiovascular disease. Intervention: COMPASS included weekly case reviews with a consulting physician and psychiatrist, a patient-tracking registry, and monitoring of hospital and emergency department use. Main Measures: Site visit reports were analyzed with Atlas.ti software to qualitatively describe implementation measures and their variation across sites. Key Results: Nine measures were identified that impacted implementation efforts across health systems: (1) challenges in health systems9 organizational environments, (2) prior care coordination experience, (3) physician engagement, (4) care team trust and cohesion, (5) care manager training and experience, (6) patient enrollment length, attainment of clinical targets, and frequency/content of care manager contacts, (7) patient-tracking registries, (8) quality improvement and outcomes monitoring reports, and (9) patients9 social needs. Conclusions: Understanding multilevel measures impacting COMPASS implementation could increase the success of future collaborative care implementation efforts.

Purpose: Practice facilitators (“facilitators”) can play an important role in supporting primary care practices in performing quality improvement (QI), but they need complete and accurate clinical performance data from practices9 electronic health records (EHR) to help them set improvement priorities, guide clinical change, and monitor progress. Here, we describe the strategies facilitators use to help practices perform QI when complete or accurate performance data are not available. Methods: Seven regional cooperatives enrolled approximately 1500 small-to-medium-sized primary care practices and 136 facilitators in EvidenceNOW, the Agency for Healthcare Research and Quality9s initiative to improve cardiovascular preventive services. The national evaluation team analyzed qualitative data from online diaries, site visit field notes, and interviews to discover how facilitators worked with practices on EHR data challenges to obtain and use data for QI. Results: We found facilitators faced practice-level EHR data challenges, such as a lack of clinical performance data, partial or incomplete clinical performance data, and inaccurate clinical performance data. We found that facilitators responded to these challenges, respectively, by using other data sources or tools to fill in for missing data, approximating performance reports and generating patient lists, and teaching practices how to document care and confirm performance measures. In addition, facilitators helped practices communicate with EHR vendors or health systems in requesting data they needed. Overall, facilitators tailored strategies to fit the individual practice and helped build data skills and trust. Conclusion: Facilitators can use a range of strategies to help practices perform data-driven QI when performance data are inaccurate, incomplete, or missing. Support is necessary to help practices, particularly those with EHR data challenges, build their capacity for conducting data-driven QI that is required of them for participating in practice transformation and performance-based payment programs. It is questionable how practices with data challenges will perform in programs without this kind of support.

PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from −28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system–owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.

PURPOSE The methods and costs to enroll small primary care practices in large, regional quality improvement initiatives are unknown. We describe the recruitment approach, cost, and resources required to recruit and enroll 500 practices in the Northwest and Midwest regional cooperatives participating in the Agency for Healthcare Research and Quality (AHRQ)-funded initiative, EvidenceNOW: Advancing Heart Health in Primary Care. METHODS The project management team of each cooperative tracked data on recruitment methods used for identifying and connecting with practices. We developed a cost-of-recruitment template and used it to record personnel time and associated costs of travel and communication materials. RESULTS A total of 3,669 practices were contacted during the 14- to 18-month recruitment period, resulting in 484 enrolled practices across the 6 states served by the 2 cooperatives. The average number of interactions per enrolled practice was 7, with a total of 29,100 hours and a total cost of $2.675 million, or $5,529 per enrolled practice. Prior partnerships predicted recruiting almost 1 in 3 of these practices as contrasted to 1 in 20 practices without a previous relationship or warm hand-off. CONCLUSIONS Recruitment of practices for large-scale practice quality improvement transformation initiatives is difficult and costly. The cost of recruiting practices without existing partnerships is expensive, costing 7 times more than reaching out to familiar practices. Investigators initiating and studying practice quality improvement initiatives should budget adequate funds to support high-touch recruitment strategies, including building trusted relationships over a long time frame, for a year or more.

PURPOSE: Since collecting outcome measure data from patients can be expensive, time-consuming, and subject to memory and nonresponse bias, we sought to learn whether outcomes important to patients can be obtained from data in the electronic health record (EHR) or health insurance claims. METHODS: We previously identified 21 outcomes rated important by patients who had advanced imaging tests for back or abdominal pain. Telephone surveys about experiencing those outcomes 1 year after their test from 321 people consenting to use of their medical record and claims data were compared with audits of the participants’ EHR progress notes over the time period between the imaging test and survey completion. We also compared survey data with algorithmically extracted data from claims files for outcomes for which data might be available from that source. RESULTS: Of the 16 outcomes for which patients’ survey responses were considered to be the best information source, only 2 outcomes for back pain and 3 for abdominal pain had kappa scores above a very modest level of ≥ 0.2 for chart audit of EHR data and none for algorithmically obtained EHR/claims data. Of the other 5 outcomes for which claims data were considered to be the best information source, only 2 outcomes from patient surveys and 3 outcomes from chart audits had kappa scores ≥ 0.2. CONCLUSIONS: For the types of outcomes studied here, medical record or claims data do not provide an adequate source of information except for a few outcomes where patient reports may be less accurate.

Engaging primary care practices in initiatives designed to enhance quality, reduce costs, and promote safety is challenging as practices are already participating in numerous projects and mandated programs designed to improve care delivery and quality. Recruiters must expand their recruitment tools to engage today’s practices in quality improvement. Using grant proposals, online diaries, observational site visits, and interviews with key stakeholders, the authors identify successful practice recruitment strategies in the EvidenceNOW initiative, which aimed to recruit approximately 1500 small- to medium-sized primary care practices. Recruiters learned they needed to articulate how participation in EvidenceNOW aligned with other initiatives and could help practices succeed with federal and state initiatives, recognition programs, and existing or future payment requirements. Recruiters, initiative leaders, and funders must now consider how their efforts align with ongoing initiatives to successfully recruit and engage practices, ease practice burden, and encourage participation in efforts that support practice transformation.

Objective The spread of evidence-based care is an important challenge in healthcare. We evaluated spread of an evidence-based large-scale multisite collaborative care model for patients with depression and diabetes and/or cardiovascular disease (COMPASS). Methods Primary care patients with depression and comorbid diabetes or cardiovascular disease were recruited. Collaborative care teams used care management tracking systems and systematic case reviews to track and intensify treatment for patients not improving. Targeted outcomes were depression remission and response (assessed with the Patient Health Questionnaire-9) and control of diabetes (assessed by HbA1c) and blood pressure. Patients and clinicians were surveyed about satisfaction with care. Results Eighteen care systems and 172 clinics enrolled 3609 patients across the US. Of those with uncontrolled disease at enrollment, 40% achieved depression remission or response, 23% glucose control and 58% blood pressure control during a mean follow-up of 11 months. There were large variations in outcomes across medical groups. Patients and clinicians were satisfied with COMPASS care. Conclusions COMPASS was successfully spread across diverse care systems and demonstrated improved outcomes for complex patients with previously uncontrolled chronic disease. Future large-scale implementation projects should create robust processes to identify and reduce expected variation in implementation to consistently provide improved care.

To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients.We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depression and diabetes and/or cardiovascular disease.Of the clinicians who responded to the survey (n=709; 46%), we found that a substantial minority (31%) were experiencing burnout that was associated with lower career satisfaction (P.0001) and lower satisfaction with resources to treat complex patients (P.0001). Less than 50% of clinicians rated their ability to treat complex patients as very good to excellent with 21% rating their ability as fair to poor. The majority of clinicians (72%) thought that a collaborative model of care would be very helpful for treating complex patients.Burnout remains a problem for primary care clinicians and is associated with low job satisfaction and low satisfaction with resources to treat complex patients. A collaborative care model for patients with mental and physical health problems may provide the resources needed to improve the quality of care for these patients.

Objective To describe a national effort to disseminate and implement an evidence-based collaborative care management model for patients with both depression and poorly controlled diabetes and/or cardiovascular disease across multiple, real-world diverse clinical practice sites. Methods Goals for the initiative were as follows: (1) to improve depression symptoms in 40% of patients, (2) to improve diabetes and hypertension control rates by 20%, (3) to increase provider satisfaction by 20%, (4) to improve patient satisfaction with their care by 20% and (5) to demonstrate cost savings. A Care Management Tracking System was used for collecting clinical care information to create performance measures for quality improvement while also assessing the overall accomplishment of these goals. Results The Care of Mental, Physical and Substance-use Syndromes (COMPASS) initiative spread an evidence-based collaborative care model among 18 medical groups and 172 clinics in eight states. We describe the initiative's evidence-base and methods for others to replicate our work. Conclusions The COMPASS initiative demonstrated that a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients. We present this model as an example of how the time gap between research and practice can be reduced on a large scale.