The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
Division of General Internal Medicine and Clinical Epidemiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
Health Serv Res. 2020 Dec;55(6):944-953. doi: 10.1111/1475-6773.13571. Epub 2020 Oct 13.
To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices.
A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018.
We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of risk-stratified adults, aged 40-79 years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention.
DATA COLLECTION/ EXTRACTION METHODS: Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry.
ASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low-income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions.
A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices. Registration: ClinicalTrials.Gov 15-0479.
评估一项干预措施的传播和实施效果，该措施包括实践促进以及基于风险分层的人群管理仪表板，以降低高危小型基层医疗实践中的患者的心血管风险。
北卡罗来纳州共有 219 家小型基层医疗实践（每个站点≤10 名临床医生），主要数据来自 2015 年第四季度至 2018 年第二季度的电子健康记录（EHR）。
我们进行了一项为期一年的干预措施的分步楔形、分层、聚类随机试验，该干预措施包括利用质量改进技术进行实践促进，以及一个心血管仪表板，其中包括按风险分层的 40-79 岁成年人列表，以及他们未得到满足的治疗机会。主要结局是所有基线评分≥10%的患者在基线至干预后 3 个月期间的 10 年 ASCVD 风险评分的变化。
数据收集/提取方法：每晚，数据从实践中安全地从他们的 EHR 传输到研究团队的注册中心。
对 437556 名患者进行了 ASCVD 风险评分评估，其中 146826 名患者的 10 年风险≥10%。平均基线风险为 23.4%（标准差±12.6%）。干预后，绝对风险降低了 6.3%（95%CI 6.3，6.4）。考虑日历时间和分步楔形控制的模型表明，大部分改善（6.3%的 4.0）归因于干预，而不是时间推移趋势。在多变量分析中，男性、年龄>65 岁、低收入（<$40000）和黑人种族（所有变量 P<0.001）均与更大的风险降低相关。
基于风险分层的人群管理仪表板与实践促进相结合，为高危患者的 10 年 ASCVD 风险带来了实质性降低。类似的方法可以有效地传播和实施其他新证据，特别是在农村和其他资源不足的实践中。注册：ClinicalTrials.Gov 15-0479。
