Departments of Pediatrics,Epidemiology and Biostatistics,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio
Epidemiology and Biostatistics,The Center for Child Health and Policy, Rainbow Babies and Children's Hospital, Cleveland, Ohio.
Pediatrics. 2014 Jun;133(6):e1664-75. doi: 10.1542/peds.2013-1578. Epub 2014 May 5.
Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services.
In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods.
Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need.
Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.
不断发展的初级保健模式需要一些方法来帮助实践达到质量标准。本研究评估了一种针对实践的促进干预措施的有效性，该措施旨在提高 3 项儿科预防服务的提供。
在这项聚类随机试验中，实践促进者实施了针对实践的快速循环反馈/变更策略，以改善肥胖筛查/咨询、铅筛查和牙科氟化物漆应用。30 个实践被随机分为早期或晚期干预组，并对 16419 次儿童健康访视进行了结果评估。一个多学科团队使用比较案例研究方法来描述促进过程。
基线表现如下：肥胖：早期实践中 3.5%的成功表现，晚期实践中 6.3%，P =.74；铅：分别为 62.2%和 77.8%，P =.11；氟化物：所有实践的成功率均<0.1%。在随机分组后 4 个月，早期实践中的表现上升，肥胖的成功率为 82.8%，铅为 86.3%，氟化物为 89.1%，所有 P 值均<0.001，与晚期实践的对照时间相比均有改善。在整个 6 个月的干预期间，所有实践中的护理均比基线有所改善，早期实践中肥胖的改善为 86.5%，晚期实践为 88.9%；早期实践中铅的改善为 87.5%，晚期实践为 94.5%；早期实践中氟化物的改善为 78.9%，晚期实践为 81.9%，所有 P 值均<0.001，与基线相比均有改善。干预后 2 个月，改善仍持续。成功的促进涉及多学科支持、快速循环问题解决反馈和持续的关系建立，允许根据 3 个实践需求水平个性化促进方法和强度。
针对实践的促进干预可以带来 3 个领域的实质性、同步和持续的改善，并且作为一种推进儿科预防保健的广泛方法具有很大的前景。
