Factors Associated With Use of Quality Improvement Strategies Among Small-to Medium Size Primary Care Practices in the United States.

Context: Improving health care quality in small-to-medium-size primary care practices, where the majority of Americans receive care, is a national priority, but little is known about these practices\u27 ability to use quality improvement (QI) strategies to deliver high quality care. Objective: To examine variations in the use of QI strategies across small-to-medium primary care practices and to assess practice-level factors associated with variations. Design: Cross-sectional study. Multivariable linear regression was used to examine the independent relationship between practice characteristics and the use of QI strategies as measured by the strategies scale of the Change Process Capability Questionnaire (CPCQ), a validated instrument designed to measure practice use of QI strategies. Setting: Data from 1,091 small-to-medium-size practices (≤10 clinicians) in 12 US states engaged in a national initiative to improve quality of care for heart health. Participants: Survey of practice leaders to assess practices characteristics and use of improvement strategies. Results: Of the practices surveyed, 84% had 10 or fewer clinicians, 21% had experienced multiple disruptive changes in the prior year, and most had meaningful use-certified electronic health records. Mean CPCQ strategies score was 8.6 (range -28 to +28, SD=12.2). Mean CPCQ scores were higher for practices that were part of accountable care organizations (+2.06, p=0.006) or had participated in demonstration projects (+1.59, p=0.04). Also, practices that discussed clinical quality data during meetings, that had someone in practice to configure EHR quality reports, and that had produced quality reports at least once in the prior six months had higher CPCQ strategies scores. Practices experiencing major disruptive changes had lower mean CPCQ scores (-3.0, p=0.001). Conclusion: Use of QI strategies varied greatly among small-to-medium-size primary care practices. Findings suggest that strengthening organizational makeup, increasing practice EHR capabilities and reducing organizational disruption could enhance the quality of care delivered by small-to-medium-size practic

A national evaluation of a dissemination and implementation initiative to enhance primary care practice capacity and improve cardiovascular disease care: the ESCALATES study protocol.

BACKGROUND: The Agency for Healthcare Research and Quality (AHRQ) launched the EvidenceNOW Initiative to rapidly disseminate and implement evidence-based cardiovascular disease (CVD) preventive care in smaller primary care practices. AHRQ funded eight grantees (seven regional Cooperatives and one independent national evaluation) to participate in EvidenceNOW. The national evaluation examines quality improvement efforts and outcomes for more than 1500 small primary care practices (restricted to those with fewer than ten physicians per clinic). Examples of external support include practice facilitation, expert consultation, performance feedback, and educational materials and activities. This paper describes the study protocol for the EvidenceNOW national evaluation, which is called Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES). METHODS: This prospective observational study will examine the portfolio of EvidenceNOW Cooperatives using both qualitative and quantitative data. Qualitative data include: online implementation diaries, observation and interviews at Cooperatives and practices, and systematic assessment of context from the perspective of Cooperative team members. Quantitative data include: practice-level performance on clinical quality measures (aspirin prescribing, blood pressure and cholesterol control, and smoking cessation; ABCS) collected by Cooperatives from electronic health records (EHRs); practice and practice member surveys to assess practice capacity and other organizational and structural characteristics; and systematic tracking of intervention delivery. Quantitative, qualitative, and mixed methods analyses will be conducted to examine how Cooperatives organize to provide external support to practices, to compare effectiveness of the dissemination and implementation approaches they implement, and to examine how regional variations and other organization and contextual factors influence implementation and effectiveness. DISCUSSION: ESCALATES is a national evaluation of an ambitious large-scale dissemination and implementation effort focused on transforming smaller primary care practices. Insights will help to inform the design of national health care practice extension systems aimed at supporting practice transformation efforts in the USA. CLINICAL TRIAL REGISTRATION: NCT02560428 (09/21/15)