Improving Prevention Systems in Primary Care Practices

Our study’s strengths include the participation of a variety of private practices in several regions, high completion and participation rates, and multiple data sources. The study methodology, including continuous monitoring, persistent reminders, modest financial incentives, and treatment of participating practices as “valued customers” throughout the study, helped achieve the high participation and completion rates. In addition, we demonstrated that this intervention model may be generalizable, as consultant faculty in 4 different regions implemented the same intervention and achieved similar results. This model could be used in managed care practice networks to improve preventive services.

Limitations

Selection bias from the volunteer practices is a possible limitation, although more than 60% of eligible practices participated, and this participation rate would have been higher if all practices that wanted to participate could have been accommodated.¹⁷ Nevertheless, our study results pertain only to the practices that participated. Although practices were randomized to interventions, each practice is different, and these differences may have affected the outcomes. For the practice variables we examined Table 2, no significant differences were noted. The intervention protocol encouraged practices to choose their own goals and allowed them to set multiple goals and change several practice systems simultaneously, providing the autonomy recommended in quality improvement projects. This flexibility may have diluted the effects of the inter- vention.,/p>

We designated the conference-only group as a control for secular changes, but the conference, the materials provided, the practices’ interest in prevention, and the knowledge that they were participating in a national trial may have influenced this group’s outcomes. On the basis of previous research, our initial hypothesis was that an educational intervention alone would have little effect.¹⁵ However, conference-only practices met with all staff and set goals at the 1-day conference, used system materials, and reported holding meetings and making system changes, which is more than expected with usual CME. There was no true control group in this study, and either secular change or the conference may explain the improvements in services noted in the conference-only group. It is also possible that because the conference-only practices set fewer goals, they were more likely to achieve them. Our results suggest that further research is needed on how a 1-day conference affects quality improvement, with protected time for group interaction and staff participation.

Conclusions

This trial demonstrates that private primary care practices will work to improve the quality of their prevention service systems. The interventions used were well received and were internalized by the practices to a significant degree. The practice system changes increased the provision and documentation of cardiovascular disease screening and management. Our study suggests that higher rates of screening are clearly related to more documentation of risk factor management, which is consistent with other studies.²⁴ Further analysis is underway to assess practice characteristics associated with improvements, to further explain intervention effects, and to evaluate patient care outcomes. Although the practice efforts and improvements in this trial were positive, further research is needed to develop more effective methods and incentives to improve preventive services in community practices.

Acknowledgments

This research is supported by a Public Health Services Grant from the National Heart, Lung, and Blood Institute, National Institutes of Health (RO1 HL-47554). We thank the Wisconsin Research Network (Madison) and HealthPartners (Minneapolis, Minn) for their collaboration. We also express our gratitude to the HEART practice physicians, staff, and patients for their willingness to participate. Wisconsin: Blue Diamond Family Practice Center, Bloomer; Community Health Center, Union Grove; Family Health Associates, Chippewa Falls; Family Health Specialists (PrimeCare Centers, SC), Wausau; Family Practice Associates, Dodgeville; Franciscan Skemp Healthcare/Mayo Health System/Onalaska Clinic, Onalaska; Franciscan Skemp Healthcare/Mayo Health System/Sparta Campus, Sparta; Grant Community Clinic, Lancaster; Grantsburg Clinic, Grantsburg; Group Health Cooperative of Eau Claire-Riverview, Eau Claire; Health Directions Delafield, Delafield; Kickapoo Valley Medical Clinic-VMH, Soldiers Grove; LacCourte Oreilles Community Health Center, Hayward; Lodi Medical Clinic, Lodi; Marshfield Clinic-Colby/Abbotsford Center, Colby; Medical Associates of Watertown, Watertown; Mercy Whitewater Medical Center, Whitewater; Milwaukee Physicians and Therapists, SC, Mequon; North Woods Community Health Center, Minong; Roche-A-Cri Clinic, SC, Friendship; Sinai Samaritan-Johnston Primary Care Clinic, Milwaukee; and United Internists of Milwaukee, SC, New Berlin. Illinois: Drs Dorsey, Rone, and Savic, Rockford; and Family Care Affiliates, Silvis. Minnesota: Camden Physicians Ltd–Camden, Minneapolis; Camden Physicians Ltd–Grove Square, Maple Grove; Consultants-Internal Medicine, Edina; Eden Prairie Clinic, Ltd, Eden Prairie; Glencoe Medical Clinic, Glencoe; Health Partners Inver Grove Heights Clinic, Inver Grove Heights; Health Partners Ridgedale Clinic, Minnetonka; Health Partners West Medical and Dental Clinic, St. Louis Park; and Health Partners White Bear Lake Clinic, White Bear Lake. Iowa: Center for Family Medicine, McFarland Clinic, PC, Marshalltown; Dyersville Family Practice, Dyersville; Elkader Medical Associates, Elkader; Family Medical Center, PC, Marion; Family Medical Center, PC, Oskaloosa; Family Medicine of Mt. Pleasant, PC, Mt. Pleasant; Manchester Family Medical Associates, PC, Manchester; Maquoketa Family Clinic, Maquoketa; Marshalltown Family Medical Services, McFarland Clinic, PC, Marshalltown; and Monticello Medical Center, Monticello.