TY - JOUR
T1 - Improving smoking and blood pressure outcomes
T2 - The interplay between operational changes and local context
AU - Cohen, Deborah J.
AU - Sweeney, Shannon M.
AU - Miller, William L.
AU - Hall, Jennifer D.
AU - Miech, Edward J.
AU - Springer, Rachel J.
AU - Balasubramanian, Bijal A.
AU - Damschroder, Laura
AU - Marino, Miguel
N1 - Publisher Copyright:
© 2021, Annals of Family Medicine, Inc. All rights reserved.
PY - 2021/5/1
Y1 - 2021/5/1
N2 - PURPOSE We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in Evidence-NOW—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. RESULTS 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. CONCLUSIONS 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.
AB - PURPOSE We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care. METHODS We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in Evidence-NOW—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. RESULTS 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. CONCLUSIONS 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.
KW - Blood pressure management
KW - Cardiovascular prevention
KW - Configurational comparative meth-ods
KW - Mixed methods
KW - Organizational change
KW - Practice-based research
KW - Primary care
KW - Quality improvement
KW - Smoking cessation
UR - http://www.scopus.com/inward/record.url?scp=85107462057&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85107462057&partnerID=8YFLogxK
U2 - 10.1370/afm.2668
DO - 10.1370/afm.2668
M3 - Article
C2 - 34180844
AN - SCOPUS:85107462057
SN - 1544-1709
VL - 19
SP - 240
EP - 248
JO - Annals of family medicine
JF - Annals of family medicine
IS - 3
ER -