Improving Quality Improvement Capacity and Clinical Performance in Small Primary Care Practices.

PURPOSE: We undertook a study to assess whether implementing 7 evidence-based strategies to build improvement capacity within smaller primary care practices was associated with changes in performance on clinical quality measures (CQMs) for cardiovascular disease. METHODS: A total of 209 practices across Washington, Oregon, and Idaho participated in a pragmatic clinical trial that focused on building quality improvement capacity as measured by a validated questionnaire, the 12-point Quality Improvement Capacity Assessment (QICA). Clinics reported performance on 3 cardiovascular CQMs-appropriate aspirin use, blood pressure (BP) control (<140/90 mm Hg), and smoking screening/cessation counseling-at baseline (2015) and follow-up (2017). Regression analyses with change in CQM as the dependent variable allowed for clustering by practice facilitator and adjusted for baseline CQM performance. RESULTS: Practices improved QICA scores by 1.44 points (95% CI, 1.20-1.68; P <.001) from an average baseline of 6.45. All 3 CQMs also improved: aspirin use by 3.98% (average baseline = 66.8%; 95% CI for change, 1.17%-6.79%; P = .006); BP control by 3.36% (average baseline = 61.5%; 95% CI for change, 1.44%-5.27%; P = .001); and tobacco screening/cessation counseling by 7.49% (average baseline = 73.8%; 95% CI for change, 4.21%-10.77%; P <.001). Each 1-point increase in QICA score was associated with a 1.25% (95% CI, 0.41%-2.09%, P = .003) improvement in BP control; the estimated likelihood of reaching a 70% BP control performance goal was 1.24 times higher (95% CI, 1.09-1.40; P <.001) for each 1-point increase in QICA. CONCLUSION: Improvements in clinic-level performance on BP control may be attributed to implementation of 7 evidence-based strategies to build quality improvement capacity. These strategies were feasible to implement in small practices over 15 months.

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons From 5 Case Studies.

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems.

A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care.

PURPOSE: We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. METHODS: Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. RESULTS: Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). CONCLUSIONS: Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

Assessing quality improvement capacity in primary care practices.

BACKGROUND: Healthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation. METHODS: To guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors. RESULTS: The QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2-5 clinicians had lower QICA scores.. CONCLUSIONS: The QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality. TRIAL REGISTRATION: This trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.

Engaging Primary Care Practices in Studies of Improvement: Did You Budget Enough for Practice Recruitment?

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.

Tokenism in patient engagement.

Background: Patient engagement throughout research is a way to generate more relevant patient-important research questions, methods and results with the ultimate aim of facilitating translation of research into practice. Tokenism is defined as the practice of making perfunctory or symbolic efforts to engage communities or patients. Objective: We wanted to explore how tokenism might influence engaging patients in research to help researchers work towards more genuine engagement. Methods: The Community Clinician Advisory Group and Patient and Clinician Engagement program held a workshop at the 2015 North American Primary Care Research Group meeting titled 'How Do We Move beyond Tokenism in Patient Engagement?' Patients, clinicians and academic researchers contributed examples of genuine and token engagement characteristics based on personal experience and knowledge. Data were iteratively collated and categorized into domains and items. Results: Examples of genuine and token engagement were categorized into three domains: Methods/Structure of engagement, Intent and Relationship building. Members with experience in patient-engaged research projects felt that longitudinal engagement was a key element to effectively translating research into local community and practice. Conclusions: The group (i) highly valued genuine intent and relationship building as elements to combat tokenism; (ii) noted that early genuine attempts at engagement may superficially resemble tokenism as researchers build enduring and trusting relationships with patient/community partners and (iii) emphasized the importance of seeking and utilizing patient experiences throughout research. These observations may contribute to more formal methods to help researchers (and reviewers) evaluate where engagement processes sit along the 'genuine-token' continuum.

A qualitative study of clinic and community member perspectives on intervention toolkits: "Unless the toolkit is used it won't help solve the problem".

BACKGROUND: Intervention toolkits are common products of grant-funded research in public health and primary care settings. Toolkits are designed to address the knowledge translation gap by speeding implementation and dissemination of research into practice. However, few studies describe characteristics of effective intervention toolkits and their implementation. Therefore, we conducted this study to explore what clinic and community-based users want in intervention toolkits and to identify the factors that support application in practice. METHODS: In this qualitative descriptive study we conducted focus groups and interviews with a purposive sample of community health coalition members, public health experts, and primary care professionals between November 2010 and January 2012. The transdisciplinary research team used thematic analysis to identify themes and a cross-case comparative analysis to explore variation by participant role and toolkit experience. RESULTS: Ninety six participants representing primary care (n = 54, 56%) and community settings (n = 42, 44%) participated in 18 sessions (13 focus groups, five key informant interviews). Participants ranged from those naïve through expert in toolkit development; many reported limited application of toolkits in actual practice. Participants wanted toolkits targeted at the right audience and demonstrated to be effective. Well organized toolkits, often with a quick start guide, with tools that were easy to tailor and apply were desired. Irrespective of perceived quality, participants experienced with practice change emphasized that leadership, staff buy-in, and facilitative support was essential for intervention toolkits to be translated into changes in clinic or public -health practice. CONCLUSIONS: Given the emphasis on toolkits in supporting implementation and dissemination of research and clinical guidelines, studies are warranted to determine when and how toolkits are used. Funders, policy makers, researchers, and leaders in primary care and public health are encouraged to allocate resources to foster both toolkit development and implementation. Support, through practice facilitation and organizational leadership, are critical for translating knowledge from intervention toolkits into practice.

Effect of a Pragmatic, Cluster-randomized Controlled Trial on Patient Experience With Care: The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Study.

BACKGROUND: Health reform programs like the patient-centered medical home are intended to improve the triple aim. Previous studies on patient-centered medical homes have shown mixed effects, but high value elements (HVEs) are expected to improve the triple aim. OBJECTIVE: The aim of this study is to understand whether focusing on HVEs would improve patient experience with care. METHODS: Eight clinics were cluster-randomized in a year-long trial. Both arms received practice facilitation, IT-based reporting, and financial incentives. Intervention practices were encouraged to choose HVEs for quality improvement goals. To assess patient experience, 1597 Consumer Assessment of Healthcare Providers and Systems surveys were sent pretrial and posttrial to a stratified random sample of patients. Difference-in-difference multivariate analysis was used to compare patient responses from intervention and control practices, adjusting for confounders. RESULTS: The response rate was 43% (n=686). Nonrespondent analysis showed no difference between arms, although differences were seen by risk status and age. The overall difference in difference was 2.8%, favoring the intervention. The intervention performed better in 9 of 11 composites. The intervention performed significantly better in follow-up on test results (P=0.091) and patients' rating of the provider (P=0.091), whereas the control performed better in access to care (P=0.093). Both arms also had decreases, including 4 of 11 composites for the intervention, and 8 of 11 for the control. DISCUSSION: Practices that targeted HVEs showed significantly more improvement in patient experience of care. However, contemporaneous trends may have affected results, leading to declines in patient experience in both arms.

Primary Care and Community-Based Partnerships to Enhance HPV Vaccine Delivery.

INTRODUCTION/OBJECTIVES: With growing vaccination misinformation and mistrust, strategies to improve vaccination communication across community-based settings are needed. METHODS: The Rural Adolescent Vaccine Enterprise (RAVE), a 5-year (2018-2022) stepped-wedge cluster randomized study, tested a clinic-based practice facilitation intervention designed to improve HPV vaccination. An exploratory aim sought to explore the use of partnerships between primary care clinics and a community partner of their choosing, to implement a social marketing campaign related to HPV immunization. We assessed perceptions about the value and success of the partnership, and barriers and facilitators to its implementation using a 29-item community partner survey, key informant interviews, and field notes from practice facilitators. RESULTS: Of the initial 45 clinics participating in RAVE, 9 were unable to either start or complete the study, and 36 participants (80.0%) were actively engaged. Of these, 16/36 clinics (44.4%) reported establishing successful partnerships, 10 reported attempting to develop partnerships (27.8%), and another 10 reported not developing a partnership (27.8%), which were often caused by the COVID-19 pandemic. The most common partnership was with public health departments at 27.3%. Other partnerships involved libraries, school districts, and local businesses. More than half (63.7%) reported that creating messages regarding getting HPV vaccination was moderately to very challenging. Just under half reported (45.5%) that messaging was hard because of a lack of understanding about the seriousness of diseases caused by HPV, parents being against vaccines because of safety concerns, and religious values that result in a lack of openness to HPV vaccines. Community partners' health priorities changed as a result of RAVE, with 80% prioritizing childhood immunizations as a result of the RAVE partnership. CONCLUSIONS: Community groups want to partner with primary care organizations to serve their patients and populations. More research is needed on how best to bring these groups together.

Association between documented family history of cancer and screening for breast and colorectal cancer.

BACKGROUND: Previous research on ascertainment of cancer family history and cancer screening has been conducted in urban settings. PURPOSE: To examine whether documented family history of breast or colorectal cancer is associated with breast or colorectal cancer screening. METHODS: Medical record reviews were conducted on 3433 patients aged 55 and older from four primary care practices in two rural Oregon communities. Data collected included patient demographic and risk information, including any documentation of family history of breast or colorectal cancer, and receipt of screening for these cancers. RESULTS: A positive breast cancer family history was associated with an increased likelihood of being up-to-date for mammography screening (OR 2.09, 95% CI 1.45-3.00 relative to a recorded negative history). A positive family history for colorectal cancer was associated with an increased likelihood of being up-to-date with colorectal cancer screening according to U.S. Preventive Services Task Force low risk guidelines for males (OR 2.89, 95% CI 1.15-7.29) and females (OR 2.47, 95% CI 1.32-4.64) relative to a recorded negative family history. The absence of any recorded family cancer history was associated with a decreased likelihood of being up-to-date for mammography screening (OR 0.70, 95% CI 0.56-0.88 relative to recorded negative history) or for colorectal cancer screening (OR 0.75, 95% CI 0.60-0.96 in females, OR 0.68, 95% CI 0.53-0.88 in males relative to recorded negative history). CONCLUSION: Further research is needed to determine if establishing routines to document family history of cancer would improve appropriate use of cancer screening.

Clinic-level differences in human papillomavirus vaccination rates among rural and urban Oregon primary care clinics.

PURPOSE: Human papillomavirus (HPV) infection contributes to vaccine-preventable malignancies. Rural populations experience lower HPV vaccination rates despite similar rates of other childhood vaccinations. Individual- and clinic-level characteristics likely contribute to this disparity, but little is known about the separate roles of each. We compared clinic-level HPV vaccination rates among rural versus urban primary care clinics, identified factors associated with HPV vaccination, and separately assessed the impact of individual- and clinic-level characteristics on rural disparities in HPV vaccination. METHODS: This cross-sectional study included 537 Oregon primary care clinics participating in the Vaccines for Children (VFC) program during 2019. Vaccination status was assessed using Oregon's ALERT Immunization Information System and included HPV vaccine ≥ 1 dose for ages 11 and 12; HPV vaccination up to date (UTD) for ages 13-17, and coadministration with tetanus, diphtheria, and acellular pertussis (Tdap). Rural versus urban clinic-level outcomes were assessed using negative binomial regression. FINDINGS: Participating clinics were 24.5% rural and 75.6% urban. Family medicine clinics comprised 71.1%; pediatrics, 16.9%; and mixed, 12.1%. Across clinics, the average proportion of patients qualifying for VFC was 43%, and non-White patients were 14.1%. The mean rate of HPV vaccine ≥1 dose was lower among rural clinics (46.9% vs 51.1%, P = .039), as was vaccination UTD (40.5% vs 49.9%, P < .001). Adjusting for differences in individual- and clinic-level characteristics, rural disparities were no longer statistically significant. CONCLUSIONS: Both individual- and clinic-level characteristics play a role in rural disparities in HPV vaccination, and modifiable clinic-level differences may be opportune targets to address these disparities.

Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings.

BACKGROUND: The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up-to-date for breast, cervical, and colorectal cancer screening. METHODS: Four primary care practices in 2 rural Oregon communities participated. Medical chart reviews that were conducted between October 2008 and August 2009 assessed insurance coverage and up-to-date status for breast, cervical, and colorectal cancer screening. Inclusion criteria involved having at least 1 health care visit within the past 5 years and being aged ≥ 55 years. RESULTS: The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests. CONCLUSIONS: Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening.

A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics.

BACKGROUND: Academic detailing is an interactive, convenient, and user-friendly approach to delivering non-commercial education to healthcare clinicians. While evidence suggests academic detailing is associated with improvements in prescribing behavior, uncertainty exists about generalizability and scalability in diverse settings. Our study evaluates different models of delivering academic detailing in a rural family medicine setting. METHODS: We conducted a pilot project to assess the feasibility, effectiveness, and satisfaction with academic detailing delivered face-to-face as compared to a modified approach using distance-learning technology. The recipients were four family medicine clinics within the Oregon Rural Practice-based Research Network (ORPRN). Two clinics were allocated to receive face-to-face detailing and two received outreach through video conferencing or asynchronous web-based outreach. Surveys at midpoint and completion were used to assess effectiveness and satisfaction. RESULTS: Each clinic received four outreach visits over an eight month period. Topics included treatment-resistant depression, management of atypical antipsychotics, drugs for insomnia, and benzodiazepine tapering. Overall, 90% of participating clinicians were satisfied with the program. Respondents who received in person detailing reported a higher likelihood of changing their behavior compared to respondents in the distance detailing group for five of seven content areas. While 90%-100% of respondents indicated they would continue to participate if the program were continued, the likelihood of participation declined if only distance approaches were offered. CONCLUSIONS: We found strong support and satisfaction for the program among participating clinicians. Participants favored in-person approaches to distance interactions. Future efforts will be directed at quantitative methods for evaluating the economic and clinical effectiveness of detailing in rural family practice settings.

The interface between U.S. primary care clinics and pharmacies for HPV vaccination delivery: A scoping literature review.

Completion of the Human Papilloma Virus (HPV) vaccine series remains low. Partnerships between primary care (PC) clinics and local pharmacies could boost vaccination rates. We conducted a scoping literature review to address what is known and what gaps exist on the interface between U.S. primary care clinics and pharmacies for HPV vaccination. We searched Ovid MEDLINE ALL file and Cumulative Index to Allied Health Literature for articles published between 1/1/2010 and 12/31/2020. Search subjects included: 1) Pharmacy HPV Vaccination, 2) Pharmacy/PC Collaboration, and 3) Pharmacy/PC Collaboration vaccination. We developed an abstraction form to collect information on research methods, settings, strengths, weaknesses and findings. We screened 407 articles for inclusion; 17 met inclusion criteria: 13 (76.5%) reported on observational/descriptive studies; 4 articles (23.5%) reported on intervention studies, none of which were conducted in rural areas. Observational studies focused on willingness to be vaccinated for HPV and facilitators and barriers for vaccination, especially at pharmacies. Many studies concluded that knowledge about and comfort with HPV vaccine administration were needed for all vaccination stakeholders (clinicians, pharmacists, parents, and patients). Intervention studies were small with weak study designs, many of which revealed that pharmacists were not successful in integrating services into broader primary care systems. Challenges included getting physicians to sign standing order protocols, poor service delivery due to engagement barriers, and low parental demand for pharmacists to administer the vaccine. In conclusion, larger more discerning studies are needed to fully understand the potential of primary care and pharmacy interactions for HPV vaccination.

Place Matters: Closing the Gap on Rural Primary Care Quality Improvement Capacity-the Healthy Hearts Northwest Study.

CONTEXT: To compare rural independent and health system primary care practices with urban practices to external practice facilitation support in terms of recruitment, readiness, engagement, retention, and change in quality improvement (QI) capacity and quality metric performance. METHODS: The setting consisted of 135 small or medium-sized primary care practices participating in the Healthy Hearts Northwest quality improvement initiative. The practices were stratified by geography, rural or urban, and by ownership (independent [physician-owned] or system-owned [health/hospital system]). The quality improvement capacity assessment (QICA) survey tool was used to measure QI at baseline and after 12 months of practice facilitation. Changes in 3 clinical quality measures (CQMs)-appropriate aspirin use, blood pressure (BP) control, and tobacco use screening and cessation-were measured at baseline in 2015 and follow-up in 2017. RESULTS: Rural practices were more likely to enroll in the study, with 1 out of 3.5 rural recruited practices enrolled, compared with 1 out of 7 urban practices enrolled. Rural independent practices had the lowest QI capacity at baseline, making the largest gain in establishing a regular QI process involving cross-functional teams. Rural independent practices made the greatest improvement in meeting the BP control CQM, from 55.5% to 66.1% (P ≤ .001) and the smoking cessation metric, from 72.3% to 86.7% (P ≤ .001). CONCLUSIONS: Investing practice facilitation and sustained QI strategies in rural independent practices, where the need is high and resources are low, will yield benefits that outweigh centrally prescribed models.

The Importance of Practice Facilitation in Primary Care When Pandemic Takes Hold: Relationships of Resilience.

The COVID-19 pandemic is unprecedented in recent history as radically and forcefully changing healthcare delivery. Practice facilitators, who often use tools of improvement science, have long played a critical role in supporting routine primary care practice transformation when healthcare system and policy changes occur. However, current events have taken many healthcare systems to the brink of collapse. Our practice facilitation team, which has a long history of sustained primary care partnerships in rural under-resourced settings, is finding creative solutions to carry forward work in research and quality improvement, and the tools of improvement science are well-suited to address rapidly changing demands of primary care during such a crisis. We reflect here on practice facilitation through the pandemic-the value of applied improvement science, and the critical necessity of strong relationships, flexibility, and creativity to support ongoing primary care partnerships.

A Taxonomy for External Support for Practice Transformation.

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.

Effect of drug sample removal on prescribing in a family practice clinic.

PURPOSE: Little is known about the impact of recent restrictions on pharmaceutical industry detailing and sampling on prescribing behavior, particularly within smaller, independent practices. The objective of this study was to evaluate the effect of a policy prohibiting prescription drug samples and pharmaceutical industry interaction on prescribing patterns in a rural family practice clinic in central Oregon. METHODS: Segmented linear regression models were used to evaluate trends in prescribing using locally obtained pharmacy claims. Oregon Medicaid pharmacy claims were used to control for secular prescribing changes. Total and class-specific monthly trends in branded, promoted, and average prescription drug costs were analyzed 18 months before and after policy implementation. RESULTS: Aggregate trends of brand name drug use did not change significantly after policy implementation. In aggregate, use of promoted agents decreased by 1.43% while nonpromoted branded agents increased by 3.04%. Branded drugs prescribed for respiratory disease declined significantly by 11.34% compared with a control group of prescribers. Relative to the control group, prescriptions of promoted cholesterol-lowering drugs and antidepressants were reduced by approximately 9.98% and 11.34%, respectively. The trend in average cost per prescription for lipid-lowering drugs was significantly reduced by $0.70 per prescription per month. Overall, average prescription drug costs increased by $5.18 immediately after policy implementation. CONCLUSIONS: Restriction of pharmaceutical industry representatives and samples from a rural family practice clinic produced modest reductions in branded drug use that varied by class. Although aggregate average costs increased, prescriptions for branded and promoted lipid-lowering agents and antidepressants were reduced.

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS.

PURPOSE: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices. METHODS: We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting. CONCLUSIONS: It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.