Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.
Ann Fam Med. 2021 May-Jun;19(3):240-248. doi: 10.1370/afm.2668.
We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care.
We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes.
In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes.
There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.
我们开展了一项研究，旨在确定与初级保健中吸烟和血压（BP）结果改善相关的条件和运营变化。
我们从参与 EvidenceNOW-一项多站点心血管疾病预防计划的 104 个实践中的一个子集有目的地抽取并采访了实践工作人员（例如，办公室经理，临床医生）。我们计算了临床质量测量的改善，目标是使接受吸烟筛查的患者比例（如果相关，则为接受咨询的患者比例）以及血压得到充分控制的高血压患者比例提高 10 个点或更多。我们分析了访谈数据以确定运营变化，并将这些变化转化为数值数据。我们使用组态比较方法评估多个因素对结果的联合影响。
在临床医生拥有的实践中，实施常规筛查、咨询和将患者与戒烟资源联系起来的工作流程，或者实施单独的文档更改或转介到资源，都会在中等程度的促进支持下，使吸烟结果改善至少 10 个点。但是，这些模式在卫生或医院系统拥有的实践或合格的联邦健康中心中并未出现。在经过医疗助理接受了准确的 BP 测量培训后，个体执业的 BP 结果改善了至少 10 个点。在更大的，临床医生拥有的实践中，当实施第二次 BP 测量时（当第一次升高时），当工作人员了解到在哪里在电子健康记录中记录此信息时，BP 结果得到了改善。在提供 50 个小时或更多的促进服务的情况下，较大的和卫生与医院系统拥有的实践实施了这些运营变化，BP 结果得到了改善。
改善吸烟或 BP 结果没有灵丹妙药。多种运营变化的组合可以带来改善，但仅在特定的实践规模和所有权或外部促进服务剂量的背景下才可以。
