Dissemination of CVD Risk Factor Treatment Among Diabetic Patients in Safety Net Clinics
Condition: Diabetes Mellitus; Cardiovascular Diseases
MeSH terms: Cardiovascular Diseases
Study type: Interventional

Summary: 
      The purpose of the ALL Study is to determine the effectiveness of the dissemination of the
      ALL intervention from an integrated care setting into Community Health Centers (CHCs) by
      measuring changes in diabetes mellitus (DM) population prescription rates for the
      medications, using a pre-post comparison within clinics and a staggered, randomized
      implementation across clinics.
    

Detailed description: 
      The ALL Initiative ('ALL') is a population-level management program developed at Kaiser
      Permanente (KP). It seeks to decrease cardiovascular disease (CVD) morbidity and mortality in
      patients with diabetes by improving rates of prescribing for guideline-concordant
      cardioprotective medications. Multiple mechanisms supported this intervention at KP. The
      investigators implemented ALL in 11 Community Health Centers (CHC) in the Portland, Oregon
      metropolitan area. To our knowledge, this was the first clinical trial testing the
      translation and implementation of a successful quality improvement (QI) initiative from a
      private, integrated care setting into CHCs.

      The investigators adapted the ALL intervention for CHCs through an iterative,
      stakeholder-driven process. The investigators then conducted a cluster-randomized pragmatic
      trial in 11 CHCs in a staggered process with six 'early' CHCs implementing the intervention
      one year before five 'late' CHCs. The investigators measured monthly rates of
      cardioprotective prescribing rates. Through segmented regression analysis, the investigators
      evaluated the intervention's effects in June 2011-May 2013. Participants included 11 CHCs
      serving ~6,500 adult patients with diabetes mellitus (DM) who were indicated for
      cardioprotective medications per national guidelines. The investigators also conducted a
      process evaluation to identify factors important to implementation success.

      Our overarching goals were to identify and resolve issues in disseminating a successful
      program from a large, well-organized health system into CHCs. The investigators hypothesized
      that cross-setting translation was feasible, and that adapting and implementing proven QI
      approaches could improve the care CHCs provide without requiring them to develop native
      initiatives. The investigators anticipated that this implementation would involve
      substantially adapting potentially 'translatable' practices and interventions, due to the
      differences between private, integrated care settings and CHCs in terms of patient needs and
      vulnerability, and system resources.
    

Intervention name(s): ALL; ALL
Intervention type(s): Other; Other
Intervention description(s): This clinic-level intervention involves a toolkit of decision support tools. These tools are listed below.
EHR tools to expedite identification
a. EHR automated point-of-care alerts (Best Practice Alerts)
EHR tools to expedite prescribing
EHR order sets
EHR text shortcuts for notation
patient education materials (handout, poster)
EHR-based outreach support tools a. EHR registries; These clinics got the same exact intervention, but one year later, as this was a staggered randomized trial.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: clinic-level interventions; quality improvement; translational medical research; community health centers