A qualitative study of processes used to implement evidence-based care in a primary care practice.

BACKGROUND: Evidence-based guidelines for care of coronary heart disease patients are not fully implemented. Primary care practices provide most of the care for these patients. OBJECTIVE: To learn how providers and staff in a busy primary care practice implement interventions to provide evidence-based care of coronary heart disease patients. METHODS: We conducted a qualitative analysis of the responses to open-ended questions in nine electronically administered bimonthly surveys of key physicians, clinic staff and managers in the practice. RESULTS: Ten to 16 (mean=12.3) personnel responded to each survey. Nearly 30% were physicians and 40.5% were clinic staff. Four major themes emerged from the qualitative analysis: (i) giving data about not-at-goal patients to providers for care plan development; (ii) developing team roles and defining tasks; (iii) providing patient care and implementing care plans and (iv) providing technology support to generate useful, accurate data. The frequency that the subthemes were mentioned varied from survey to survey, but their mention persisted over the entire time of all nine surveys. CONCLUSIONS: Developing a system for implementing evidence-based care involves considerations of roles and teamwork, technology use to develop a patient registry and obtain needed clinical data, care processes for pre-visit planning, and between-visit care management. A registered nurse care manager is a central figure in implementing and sustaining the process. Implementing evidence-based guidelines is an ongoing process of revision, retraining and reinforcement.

The financial impact of team-based care on primary care.

OBJECTIVES: Although team-based care can improve coronary heart disease (CHD) risk factors and is considered cost-effective from a healthcare system perspective, little is known about the financial impact of team-based primary care for secondary prevention of CHD. The purpose of this study was to define the impact of team-based care for CHD on utilization, costs, and revenue of a private primary care practice. STUDY DESIGN: Interrupted time series analysis. METHODS: Between March 1, 2010, and March 31, 2013, we assisted a private medical practice, comprising 5 primary care clinic sites, to organize and deliver team-based care for patients with CHD. We used billing records and the registered nurse care manager's diary to calculate the cost of team-based care, differences in the average number of visits per patient, and revenue per patient before and after the implementation of team-based care. RESULTS: The net cost of team-based primary care was $291 per patient over the 1-year period of observation. CONCLUSIONS: The findings from this study are consistent with other economic analyses of team-based care and suggest that payment for care must be restructured if patients are expected to enjoy the benefits of team-based primary care.

Using Principles of Complex Adaptive Systems to Implement Secondary Prevention of Coronary Heart Disease in Primary Care.

CONTEXT: Primary care practice. OBJECTIVE: To test whether the principles of complex adaptive systems are applicable to implementation of team-based primary care. DESIGN: We used complex adaptive system principles to implement team-based care in a private, five-clinic primary care practice. We compared randomly selected samples of patients with coronary heart disease (CHD) and diabetes before system implementation (March 1, 2009, to February 28, 2010) and after system implementation (December 1, 2011, to March 31, 2013). MAIN OUTCOME MEASURES: Rates of patients meeting the composite goals for CHD (blood pressure < 140/90 mmHg, low-density lipoprotein cholesterol level < 100 mg/dL, tobacco-free, and using aspirin unless contraindicated) and diabetes (CHD goal plus hemoglobin A1c concentration < 8%) before and after the intervention. We also measured provider and patient satisfaction with preventive services. RESULTS: The proportion of patients with CHD who met the composite goal increased from 40.3% to 59.9% (p < 0.0001) because documented aspirin use increased (65.2%-97.5%, p < 0.0001) and attainment of the cholesterol goal increased (77.0%-83.9%, p = 0.0041). The proportion of diabetic patients meeting the composite goal rose from 24.5% to 45.4% (p < 0.0001) because aspirin use increased (58.6%-97.6%, p < 0.0001). Increased percentages of patients meeting the CHD and diabetes composite goals were not significantly different (p = 0.2319). Provider satisfaction with preventive services delivery increased significantly (p = 0.0017). Patient satisfaction improved but not significantly. CONCLUSION: Principles of complex adaptive systems can be used to implement team-based care systems for patients with CHD and possibly diabetic patients.

The TEAM project: the effectiveness of smoking cessation intervention with hospital patients.

BACKGROUND: This study evaluated the effectiveness of three smoking cessation interventions for this population: (1) modified usual care (UC); (2) brief advice (A); and (3) brief advice plus more extended counseling during and after hospitalization (A + C). METHODS: Smokers (2,095) who were in-patients in four hospitals were randomly assigned to condition. Smoking status was ascertained via phone interview 7 days and 12 months post-discharge. At 12 months, reports of abstinence were validated by analysis of saliva cotinine. Intent to treat analyses were performed. RESULTS: At 7-day follow-up, 24.2% of participants reported abstinence in the previous 7 days. There were no differences between conditions. At 12-month follow-up, self-reported abstinence was significantly higher in the A + C condition (UC (15.0%) vs. A (15.2%) vs. A + C (19.8%)). There was no significant difference among conditions in cotinine-validated abstinence, however (UC (8.8%) vs. A (10.0%) vs. A + C (9.9%)). CONCLUSIONS: These interventions for hospital in-patients did not increase abstinence rates. Features of the study that might have contributed to this finding were the inclusiveness of the participation criteria, the fact that pharmacological aids were not provided, and a stage-matching approach that resulted in less intensive counseling for participants unwilling to set a quit date.