Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial

Ann Fam Med. 2014 Jan-Feb;12(1):8-16. doi: 10.1370/afm.1591.


Purpose: We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

Methods: We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

Results: Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.

Conclusions: Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.

Keywords: diabetes mellitus; family medicine; patient-centered medical home; practice facilitation; practice-based research; primary health care; quality improvement.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Diabetes Mellitus / therapy*
  • Family Practice / methods*
  • Family Practice / organization & administration
  • Family Practice / standards
  • Female
  • Humans
  • Male
  • Middle Aged
  • Outcome and Process Assessment, Health Care
  • Patient-Centered Care / methods
  • Patient-Centered Care / organization & administration
  • Patient-Centered Care / standards
  • Primary Health Care / methods*
  • Primary Health Care / organization & administration
  • Primary Health Care / standards
  • Quality Improvement