The Northwest Coalition for Primary Care Practice Support

Study Overview
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Brief Summary
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The purpose of this project is to build capacity for quality improvement (QI) in small primary care practices across Washington, Oregon and Idaho by improving risk factors for heart attacks such as blood pressure, cholesterol and smoking. The Northwest Coalition for Primary Care Practice Support will assist practices by providing them with a QI coach, creating group learning opportunities, and conducting educational outreach activities. An innovative study design will be used to determine what levels and types of support are most helpful and effective.

Detailed Description
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The Northwest Coalition for Primary Care Practice Support will provide a comprehensive and robust external practice support infrastructure for small and medium primary care practices across Washington (WA), Oregon (OR) and Idaho (ID) to build their internal quality improvement (QI) capacity and improve performance on the heart health indicators of aspirin use, blood pressure and cholesterol control and smoking cessation (ABCS indicators) by disseminating and supporting the implementation of relevant Patient Centered Outcomes Research findings. This coalition of partners has a remarkable track record of collaboration and improving primary care practice: the MacColl Center for Health Care Innovation and the Center for Community Health Evaluation at Group Health Research Institute; Qualis Health, the Health IT Regional Extension Center (REC) and designated Quality Improvement Organization (QIO) for WA and ID; and the Oregon Rural Practice-based Research Network (ORPRN), along with state-level partners who are membership organizations for clinicians in small practice settings. Recruitment will leverage existing small practice relationships between Qualis Health as the health information technology (IT) REC for WA and ID and ORPRN's existing network of small practices with a goal of enrolling 320 small practices out of an estimated 1,479 with stage 1 meaningful use of their electronic health record across the three states. In addition to providing health IT support for the Physician Quality Reporting System (PQRS) to measure the ABCS indicators in all practices, our comprehensive approach to building QI capacity and improving the ABCS measures consists of: 1) practice facilitation as a unifying strategy, 2) academic detailing/outreach to support implementation of PCOR findings, and 3) shared learning collaboratives. We will employ an innovative study and evaluation design by providing two levels of support for each of the latter three practice support components. By randomly assigning practices to one of eight possible combinations of practice support, we will …develop new evidence about the contribution of various components of the comprehensive approach and the effect of the intensity of the approach on outcomes. Our rigorous mixed-method evaluation is based on the RE-AIM framework and will employ multi-level models and interrupted time series regression. Data will be collected from a control group of practices to examine secular trends. Our Specific Aims are to: 1) Identify, recruit and conduct baseline assessments in 320 small to medium size primary care practices across the geographically contiguous region of WA, OR and ID; 2) Provide comprehensive external practice support to build QI capacity within these practices; 3) Disseminate and support the adoption of PCOR findings relevant to the ABCS quality measures; 4) Conduct a rigorous evaluation of the effectiveness of providing external practice support to implement PCOR findings and improve ABCS measures; and 5) Assess the sustainability of changes made in QI capacity and ABCS improvements and develop a model of dissemination and primary care practice support infrastructure.

Official Title
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The Northwest Coalition for Primary Care Practice Support

Conditions
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Cardiovascular Disease, Essential Hypertension, Nicotine Dependence, Hyperlipidemia

Intervention / Treatment
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* Other: Coaching
* Other: Educational Outreach
* Other: Site Visits


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Primary care practice with 10 or fewer providers and an Electronic Health Record (EHR) that meets Stage 1 meaningful use criteria Exclusion Criteria: No EHR
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Coaching<br>External facilitation by a practice coach for 15 months | Other: Coaching<br>* An external facilitator or coach is assigned 15-20 primary care clinics and will make face-to-face site visits and monthly phone calls for 15 months to support building QI capacity in each assigned practcie<br>* Other names: Practice Facilitation;|
| Active Comparator: Educational Outreach<br>Academic detailing phone calls to support implementation of a cardiovascular risk calculator/estimator in each clinic | Other: Coaching<br>* An external facilitator or coach is assigned 15-20 primary care clinics and will make face-to-face site visits and monthly phone calls for 15 months to support building QI capacity in each assigned practcie<br>* Other names: Practice Facilitation;Other: Educational Outreach<br>* Practices randomized to this arm of the study will receive an educational outreach phone call by an academic expert on implementation strategies for use of a cardiovascular risk calculator within their daily work flow and clinic setting<br>* Other names: Academic Detailing;|
| Active Comparator: Site Visit<br>Site visits made by practices to 'exemplar practices to learn innovative approaches to quality improvement | Other: Coaching<br>* An external facilitator or coach is assigned 15-20 primary care clinics and will make face-to-face site visits and monthly phone calls for 15 months to support building QI capacity in each assigned practcie<br>* Other names: Practice Facilitation;Other: Site Visits<br>* Practices randomized to this arm of the study will be given an opportunity to make a site visit to an exemplar practice to learn about innovative approaches to conducting quality improvement activities.<br>* Other names: Peer-to-peer learning;|
| Active Comparator: Educational Outreach and Site Visit<br>In this arm of the study, practices will be offered both educational outreach and an opportunity for a site visit | Other: Coaching<br>* An external facilitator or coach is assigned 15-20 primary care clinics and will make face-to-face site visits and monthly phone calls for 15 months to support building QI capacity in each assigned practcie<br>* Other names: Practice Facilitation;Other: Educational Outreach<br>* Practices randomized to this arm of the study will receive an educational outreach phone call by an academic expert on implementation strategies for use of a cardiovascular risk calculator within their daily work flow and clinic setting<br>* Other names: Academic Detailing;Other: Site Visits<br>* Practices randomized to this arm of the study will be given an opportunity to make a site visit to an exemplar practice to learn about innovative approaches to conducting quality improvement activities.<br>* Other names: Peer-to-peer learning;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Appropriate use of Aspirin | National Quality Forum (NQF) 0068 Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic | Every 3 months with 12 month look-back | 
| Hypertension | NQF 0018 Controlling hypertension | Every 3 months with 12 month look-back | 
| Smoking | NQF 0027 Smoking and Tobacco Use Cessation, Medical Assistance | Every 3 months with 12 month look-back | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change Process Capacity | The change process capacity questionnaire | Baseline, 15 months, 21 months | 
| Quality Improvement Capacity Assessment | Practice-level consensus agreement on QI capacity | Baseline and 12 months |