The Logic Behind a Multimethod Intervention to Improve Adherence to Clinical Practice Guidelines in a Nationwide Network of Primary Care Practices

University of Southern California, USA.
Evaluation &amp the Health Professions (Impact Factor: 1.91). 04/2006; 29(1):65-88. DOI: 10.1177/0163278705284443
Source: PubMed


The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

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    • "Family practice is an ideal setting for most chronic disease prevention and screening (CDPS) actions and there are several evidence-based tools and strategies available to improve CDPS, but they are inconsistently applied [3-17]. Examples include the use of electronic medical records (EMR), reminder systems [11], evidence-based guidelines and tools for CDPS actions, patient targeted interventions such as self-management tools [8-10,12,13], and practice-based quality improvement strategies such as practice facilitators [4,6,7,14-16,18]. "
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    ABSTRACT: Our randomized controlled trial (The BETTER Trial) found that training a clinician to become a Prevention Practitioner (PP) in family practices improved chronic disease prevention and screening (CDPS). PPs were trained on CDPS and provided prevention prescriptions tailored to participating patients. For this embedded qualitative study, we explored perceptions of this new role to understand the PP intervention. We used grounded theory methodology and purposefully sampled participants involved in any capacity with the BETTER Trial. Two physicians and one coordinator in each of two cities (Toronto, Ontario and Edmonton, Alberta) conducted eight individual semi-structured interviews and seven focus groups. We used an interview guide and documented research activities through an audit trail, journals, field notes and memos. We analyzed the data using the constant comparative method throughout open coding followed by theoretical coding. A framework and process involving external and internal practice facilitation using the new role of PP was thought to impact CDPS. The PP facilitated CDPS through on-going relationships with patients and practice team members. Key components included: 1) approaching CDPS in a comprehensive manner, 2) an individualized and personalized approach at multiple levels, 3) integrated continuity that included linking the patients and practices to CPDS resources, and 4) adaptability to different practices and settings. The BETTER framework and key components are described as impacting CDPS through a process that involved a new role, the PP. The introduction of a novel role of a clinician within the primary care practice with skills in CDPS could appropriately address gaps in prevention and screening.
    BMC Family Practice 04/2014; 15(1):66. DOI:10.1186/1471-2296-15-66 · 1.67 Impact Factor
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    • "In order to improve the quality of care for fall prevention provided to outpatient veterans at VAGLAHS, we envisioned a program development process that would harmonize stakeholder interests towards the goal of producing a pilot fall prevention program that could be implemented, sustained, and further improved. In keeping with previous work on translating research into practice [17], we drew on multiple theories, as well as previous experience, to plan program development and implementation. We built on organizational theory [18], previous efforts to set strategic priorities within the VA [19], diffusion of innovations theory [20], and (for implementation) principles of continuous quality improvement [21]. "
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    ABSTRACT: Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development. We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement. The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it. A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.
    BMC Health Services Research 11/2009; 9(1):206. DOI:10.1186/1472-6963-9-206 · 1.71 Impact Factor
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    • "By implementation strategies, we refer to specific interventions (e.g., academic detailing, grand rounds presentations) that are deployed to provide the necessary information, knowledge, skills, incentives, and the infrastructure for adherence. The potential importance of multi-faceted implementation strategies is well recognized in implementation research [10-12]. However, prior studies have focused mostly on the effects of multi-faceted implementation strategies on adherence to guidelines but not provider acceptance. "
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    ABSTRACT: The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs. Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models. For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used. Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.
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