A Multimethod Quality Improvement Intervention To Improve Preventive Cardiovascular Care

A Cluster Randomized Trial

5 October 2004 | Volume 141 Issue 7 | Pages 523-532

Background: Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care.

Objective: To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke.

Design: 2-year randomized, controlled clinical trial with the practice as the unit of randomization.

Setting: 20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record.

Participants: 44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87 291 patients.

Interventions: All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches.

Measurements: The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator.

Results: Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0–percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]).

Limitations: The study involved a small number of practices and lacked a pure control group.

Conclusions: Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.

Editors' Notes Context Interventions to promote guideline-recommended care have met with limited success. Quality improvement experts believe that multicomponent interventions are more effective than simpler strategies, but this belief rests on limited evidence. Contribution In this randomized trial of 20 primary care practices, intervention practices received quarterly site visits and 2 network meetings about quality improvement in addition to copies of practice guidelines and quarterly performance reports. Intervention practices had greater improvement in providing guideline-recommended care for cardiovascular disease prevention and treatment than practices that received only the guidelines and performance reports. Cautions The study involved a small number of practices. –The Editors

 

Author and Article Information

From Medical University of South Carolina, Charleston, South Carolina, and University of Southern California, Los Angeles, California.

Grant Support: By the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Public Health Service (grant no. 1 U18 HS11132-01).

Potential Financial Conflicts of Interest:Consultancies: S. Ornstein, C. Feifer, L. Dickerson, C. Litvin (Physician MicroSystems, Inc.); Grants received: S. Ornstein (Physician MicroSystems, Inc.); Royalties: S. Ornstein (Physician MicroSystems, Inc.).

Requests for Single Reprints: Steven Ornstein, MD, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, Charleston, SC 29425; e-mail, ornstesm{at}musc.edu.

Current Author Addresses: Drs. Ornstein and Litvin, Ms. Jenkins, and Ms. Roylance: Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, Charleston, SC 29425.

Dr. Nietert: Department of Biostatistics, Bioinformatics, and Epidemiology, Medical University of South Carolina, 135 Cannon Street, Charleston, SC 29425.

Dr. Feifer: Department of Family Medicine, University of Southern California, 1000 South Fremont Avenue, Building A7, Room 7419, Alhambra, CA 91803.

Ms. Nemeth: Care Management, Research/Evaluation, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425.

Dr. Corley: Internal Medicine Associates, 3715 Moss Drive, Annandale, VA 22003.

Dr. Dickerson: University Family Medicine, Medical University of South Carolina, 9298 Medical Plaza Drive North, Charleston, SC 29408.

Dr. Bradford: Health Administration and Policy, Medical University of South Carolina, 19 Hagood Avenue, Room 401, Charleston, SC 29425.