Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado.
Ann Fam Med. 2014 Jan-Feb;12(1):8-16. doi: 10.1370/afm.1591.
We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.
We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.
Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.
Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.
我们研究了 3 种实施慢性病护理模式的方法，以改善糖尿病护理：（1）使用反思性适应过程（RAP）方法进行 6 个月的实践促进；（2）使用持续质量改进（CQI）方法进行长达 18 个月的实践促进；（3）向自我指导（SD）实践提供模型信息和资源，而不提供促进。
我们进行了一项名为“增强实践，改善护理（EPIC）”的集群随机试验，该试验比较了 40 家小型到中型初级保健实践中的这些方法。在基线以及注册后 9 个月和 18 个月，我们从图表审核评估实践糖尿病质量指标，并从临床医生和员工调查评估实践文化评估分数。
尽管所有 3 组的糖尿病护理质量都有所改善（均 P <.05），但 CQI 实践组的改善程度大于 SD 实践组（P <.0001）和 RAP 实践组（P <.0001）；此外，SD 实践组的改善程度大于 RAP 实践组（P <.05）。在 RAP 实践中，Change Culture 分数在 9 个月时显示出改善的趋势（P =.07），但在 18 个月时降至基线以下（P <.05），而 Work Culture 分数从 9 个月到 18 个月下降（P <.05）。SD 和 CQI 实践中，这两个分数随时间保持稳定。
传统的 CQI 干预措施在改善糖尿病护理质量的衡量标准方面是有效的，但可能不会改善实践变化和工作文化。基于 RAP 原则的短期实践促进在质量衡量标准方面的改善程度不如 CQI 或 SD 干预措施，也没有在实践文化方面产生持续的改善。
