A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care

Abstract

Purpose: We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance.

Methods: Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach.

Results: Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76).

Conclusions: Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

Keywords: cardiovascular disease; chronic illness; health promotion; health services; organizational change; practice-based research; prevention; primary health care; quality improvement; quantitative methods.

Figure 1

CONSORT diagram of practices in the Healthy Hearts Northwest (H2N) randomized trial. CONSORT = Consolidated Standards of Reporting Trials; EOV = educational outreach visit; PF = practice facilitation; SL = shared learning.

Figure 2

Achievement of Million Hearts goal of ≥70% of eligible patients with controlled blood pressure (<140/90 mm Hg) at follow-up (2017). BP = blood pressure; CQM = clinical quality measure; EOV = educational outreach visit; PF = practice facilitation; RR = relative risk; SL = shared learning.