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.

Federal Research Funding for Family Medicine: Highly Concentrated, with Decreasing New Investigator Awards.

A small proportion of National Institutes of Health and other federal research funding is received by university departments of family medicine, the largest primary care specialty. That limited funding is also concentrated, with roughly a quarter of all National Institutes of Health, Centers for Disease Control and Prevention, and Agency for Healthcare Research and Quality funding awarded to 3 departments, almost half of that funding coming from 3 agencies, and a recent trend away from funding for new investigators.

Evaluating the Productivity of VA, NIH, and AHRQ Health Services Research Career Development Awardees.

PURPOSE: To evaluate the academic advancement and productivity of Department of Veterans Affairs Health Services Research and Development (HSR&D) Career Development Award (CDA) program recipients, National Institutes of Health (NIH) K awardees in health services research (HSR), and Agency for Healthcare Research and Quality (AHRQ) K awardees. METHOD: In all, 219 HSR&D CDA recipients from fiscal year (FY) 1991 through FY2010; 154 NIH K01, K08, and K23 awardees FY1991-FY2010; and 69 AHRQ K01 and K08 awardees FY2000-FY2010 were included. Most data were obtained from curricula vitae. Academic advancement, publications, grants, recognition, and mentoring were compared after adjusting for years since award, and personal characteristics, training, and productivity prior to the award. RESULTS: No significant differences emerged in covariate-adjusted tenure-track academic rank, number of grants as primary investigator (PI), major journal articles as first/sole author, Hirsch h-index scores, likelihood of a journal editorship position or membership in a major granting review panel, or mentoring postgraduate researchers between the HSR&D CDA and NIH K awardees from FY1991-FY2010, or among the three groups of awardees from FY2000 or later. Among those who reported grant funding levels, HSR&D CDAs from FY1991-2010 had been PI on more grants of $100,000 than NIH K awardees. HSR&D CDAs had a higher mean number of major journal articles than NIH K awardees from FY1991-2010. CONCLUSIONS: Findings show that all three HSR career development programs are successfully selecting and mentoring awardees, ensuring additional HSR capacity to improve the quality and delivery of high-value care.

Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.

Over a decade ago it was estimated that in the United States 98,000 patients die each year from hospital acquired conditions (HAC). Recently it has been reported that this many patients now die annually from hospital acquired infections (HAI) alone. Currently, HAI affects 1.7 million U.S. citizens each year. Although these conditions are often called "preventable errors," some are associated with particular hospital and physician cultures, and many of these conditions, such as pressure ulcer formation and infections, may be a sign of low facility staffing levels. Protocols have been developed that have been shown to lower the incidence of many HAC, but these have been slow to be adopted. Voluntary reporting mechanisms to ensure health care quality are reported as having reduced effectiveness by the Joint Commission and U.S. Department of Health and Human Services, Office of Inspector General reports. Transparency and public education have also met with resistance, but in the case of infections now have the support of major national medical organizations. As a further initiative to promote quality, financial incentives have been implemented by the Centers for Medicare and Medicaid Services. Surgeons have lived under stringent financial incentives since the mid-1980s when they were placed under global surgical fees. Medicare currently must make expenditure reductions because it is at risk of becoming insolvent within the decade. Implementation of financial incentives should depend upon a balance between the nonpayment of providers for nonpreventable HAC verses the promotion of health care quality and patient safety, the reduction in patient morbidity and mortality, the spurring of mechanisms to further reduce HAC, and the recouping of taxpayer dollars for HAC that could have been prevented.