Improving Prevention Systems in Primary Care Practices

Intervention Groups

The interventions were delivered at the practice level, because physician behavior is influenced by practice organizational systems and practice support mechanisms are required for sustained improvements.^10,11,14,15 Randomization of practices in each region was balanced across the 4 intervention conditions and occurred after the regional conference Figure 6. Physicians and staff could not be blinded to the interventions.

Conference-only group. A 1-day conference and HEART Kits were provided to the practices in each of the 4 groups. The conference was designed to serve as an incentive for practice participation and to efficiently impart concepts that were the basis for the other interventions. The conference-only group was considered a suitable control, because most of the physicians had been previously exposed to heart disease prevention continuing medical education (CME), and a conference was thought to be inadequate to initiate and sustain practice system change.^7,15

The HEART Kit provided a workbook describing implementation of a practice prevention system, a patient education manual, medical record tools (patient questionnaire, problem lists, flow sheet, and chart labels), patient education materials (smoking, cholesterol, hypertension, weight reduction, and exercise), and professional references (articles, protocols, and flow charts). The kit provided tools and materials that practices could choose to implement. Those materials—simple, reproducible, and adaptable for a variety of practices—were presented during the conference to model and encourage their use. These materials are available on the Internet at www.fammed.wisc.edu/research.heart.

The theme of the conference and intervention protocols was “Screen, Manage, and Monitor,” representing an ongoing cycle of both preventive patient care and practice quality improvement strategies. Medical record tools, such as the problem list and patient questionnaire, were encouraged as efficient methods to screen and document health histories and risk factors. Medical record labels were encouraged as risk factor reminders, and flow sheets were suggested to improve risk management and monitoring. Changes in organizational systems and practice roles and routines to improve cardiovascular disease prevention services were recommended, and physician and staff teams from each practice met to evaluate their existing practice system and roles. Practices were encouraged to identify goals for improving prevention systems, choosing the risk factors they intended to address and the methods they planned to use.

Conference consistency in each region was ensured, because the conference was developed and primarily presented by the principal investigator and a coinvestigator with assistance from consultant faculty teams in the other regions.

Consultation group. These practices received a series of 3 consultation meetings and 2 reinforcement visits during a 1-year period. Figure 7 Consultations were held at the practice sites, initiated within 3 months of the conference, and designed to include all participating physicians and staff. The consultant faculty followed a specific protocol, and we observed a consultation in each region to ensure uniformity of consultation methodology and format.

At the first consultation, the HEART faculty presented data from the baseline medical record review and patient, physician, and staff questionnaires, describing the baseline practice prevention activity. This practice profile provided feedback for discussion of systems improvement. Each practice chose their own goals and action plans from the HEART target areas: screening, management, and monitoring of smoking, cholesterol, and hypertension. The practice was asked to identify 2 prevention leaders (one physician and one staff member) to lead meetings, encourage practice goals, and coordinate quality improvement activities.

At the second consultation approximately 2 months later, the practice prevention leaders presented goals and an implementation plan to the practice for discussion, modification, and endorsement. HEART consultants facilitated the second and third consultations to transition the leadership and responsibility to the practice. The third consultation emphasized ongoing monitoring and evaluation of practice goals and implementation efforts.

Nurse or dietitian HEART faculty held 2 reinforcement meetings with the leaders at the practice between consultations to review progress with goals, discuss barriers or problems, and provide advice or resources for further improvement.

Prevention coordinator group. These practices worked with HEART to select an individual who would devote 4.5 hours per week per participating physician to HEART activities for the intervention year. The role of the prevention coordinator was limited to cardiovascular disease activities, including assessment, facilitation, and coordination of prevention systems (one third of the prevention coordinator’s time) and coordination and provision of patient cardiovascular disease risk education (two thirds of the prevention coordinator’s time). The prevention coordinator was preferably a current practice staff member hired for extra time, but more commonly this person was someone new to the practice. The HEART grant funded prevention coordinator salaries, training, and evaluation.

A health educator and regional HEART faculty trained the prevention coordinators in an intensive 2-day skills-development workshop. The training included a study overview, definition of the systems approach and the prevention coordinator role, health education principles, and a detailed risk factor update. Regional nurse or dietitian HEART faculty provided ongoing prevention coordinator support through regular phone contacts (at least once per month), review of daily activity logs, and occasional practice visits (2 per prevention coordinator). HEART also provided support through regional conference calls (2 per prevention coordinator), newsletters (4 per prevention coordinator), and a toll-free telephone line.