Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial.
Ann Fam Med. 2014 May-Jun;12(3):233-40.
Mold JW, Fox C, Wisniewski A, Lipman PD, Krauss MR, Harris DR, Aspy C, Cohen RA, Elward K, Frame P, Yawn BP, Solberg LI, Gonin R.
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
PURPOSE: Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined.
METHODS: In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute’s Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar’s test and multivariate modeling were used to evaluate the impact of the interventions.
RESULTS: Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation.
CONCLUSIONS: Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.
KEYWORDS: asthma; practice facilitation; practice guidelines as topic; practice-based research network; primary health care; quality improvement
The study by Mold et al. studied two promising types of assistance to improve implementation of a common chronic disease guideline [asthma] in primary care practices; practice facilitation (PF)1-3 and learning collaboratives (LLC)4-8. Assumptions behind using PF are that many practices are inadequately resourced, lack the experience and skills required, and are so unique that each must implement innovations differently.
In addition to receiving performance feedback, academic detailing, summaries of NHLBI asthma guidelines, and a toolkit, practices assigned to PF and to PF + LLC received assistance from a practice facilitator who visited practices for a half-day weekly or a full day every other week for 6 months to assist the practice in meeting their target goals.
Of the 2,226 patients meeting abstraction criteria for being asthmatic, 211 had no asthma-related visits during the 27-month study period, and 12 did not include all required information, leaving 2,003 patients with 7,106 visits for whom asthma was addressed. However, among these patients, only 1,016 (50.7%) had at least one asthma-related visit in both the pre- and post-intervention periods.
Despite much smaller numbers of asthmatic patients than expected, using multivariate GEE modeling Mold et al, demonstrated that study arm and study period (pre versus post) each contributed significantly to the assessment of severity and assessment of level of control.
Baseline levels of implementation of the six guidelines for asthma varied greatly by guideline and study arm, with evidence of a written action plan being the lowest (7% overall at baseline) to prescription for controller medication among diagnosed persistent asthmatics being the highest (82% overall at baseline). Although change in presence of a written asthma action plan did not differ by study arm (P = .24), all study arms significantly improved implementing a written action plan [Figure 1]. Critical to understanding why there was an extremely low implementation of asthma action plans is that only 9.5% (97 /1,016) of all asthmatics included in this study were ever classified as having persistent asthma. Prescription of controller medications for persistent asthmatics was high at baseline among all study arms therefore it was difficult to demonstrate an improvement when comparing pre to post by study arm [Figure 2].
Importance of this study
The unique aspect of this cluster randomized controlled trial was the ability to compare each intervention with the control arm, which provided additional evidence of the effectiveness of PF in motivating and supporting practice change.
Many patients with a diagnosis of asthma in billing records did not have evidence of asthma in the medical record, had mild disease, or were seen occasionally with only ~50% of asthmatics seen two or more times in a 27 month period in these primary care practices. This observation suggests that many asthmatics seeking care from primary care physicians may not be experiencing severe asthma.
Caution must be used when examining the implementation of clinical guidelines to ensure that patients actually require all recommended clinical guidelines.
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