Practice based education to improve delivery systems for prevention in primary care: randomised trial
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《英国医生杂志》
Peter A Margolis, professor of pediatrics and epidemiology1, Carole M Lannon, associate professor of pediatrics and internal medicine1, Jayne M Stuart, assistant professor of pediatrics1, Bruce J Fried, associate professor of health policy and administration2, Lynette Keyes-Elstein, assistant director of biostatistics3, Donald E Moore, Jr, director, division of continuing medical education4
1 University of North Carolina at Chapel Hill, North Carolina Center for Children's Healthcare Improvement, 730 Airport Rd, Ste 104, CB#7226, Chapel Hill, NC 27599, USA, 2 University of North Carolina at Chapel Hill, School of Public Health, Department of Health Policy and Administration, Chapel Hill, 3 Rho Inc, Chapel Hill, NC 27514, USA, 4 Vanderbilt University School of Medicine, Nashville, TN 37232, USA
Correspondence to: P A Margolis Peter_Margolis@med.unc.edu
Abstract
Preventive services are the cornerstone of primary care for children. Yet only about 75% of 2 year olds are fully immunised,1 and rates of preventive services such as screening for anaemia, tuberculosis, lead, and vision defects are disappointingly low. The large number of age specific preventive services recommended in the first five years of life2 3 and the time constraints under which primary care physicians practise make it easy for clinicians to overlook opportunities for preventive care.
The challenge of achieving more reliable delivery of preventive services highlights the need for a more systematic approach.4 Recent studies have shown that better "office systems" can improve the delivery of preventive care.5 Office systems are defined as an organised series of interrelated activities carried out by several members of staff to achieve a specific purpose (for example, billing). Office systems for prevention are focused on interactions of patients, staff, and clinicians, ensuring that each step of the process of preventive care is carried out for every eligible patient at every encounter. The primary hypothesis for our study was that practices that received continuing medical education (CME) in combination with process improvement methods to implement office systems would have higher rates of four core preventive services than practices that did not.
Methods
Practices and characteristics
Of the practices screened for eligibility, 88 met the inclusion criteria (figure 1). After contact for recruitment, 24 were found ineligible. Eligible practices were stratified into blocks and recruited until the target number of practices was achieved. Of the 59 practices recruited, 44 (75%) agreed to be randomised. In the intervention group, one did not participate in the intervention and three dropped out after they went bankrupt. In the control group, one practice went bankrupt during the study and dropped out.
Fig 1 Recruitment process. *The five practices "not asked to participate" were not selected for recruitment because the target sample size had been achieved
Randomisation produced intervention and control practices with comparable baseline rates of preventive services (table 1) and practice characteristics (table 2). Control practices were twice as likely to be physician owned. Only about 11% of children across all practices had all four preventive services documented in their charts; lead and tuberculosis screening were particularly low.
Table 1 Mean (SD) percentage of patients with age appropriate preventive services in intervention and control practices at baseline.
Table 2 Characteristics of participating practices at baseline. Unless indicated otherwise, values are mean (minimum, maximum)
Implementation of intervention
Practices in the intervention group were followed for an average of 24 months after the beginning of the intervention. During the implementation period, all intervention practices developed improvement teams. Project teams met with practice improvement teams a median 8.5 times (range 5-14 times). Of the 22 intervention practices, 18 (82%) implemented preventive services summaries in patient charts, 17 (77%) used tools to support risk assessments, 15 (68%) used prompting by clinicians, and 7 (32%) instituted new health maintenance records for well child visits.
Effectiveness of intervention
Figure 2 shows the pattern of change over time in the proportion of children per practice with all four preventive services in intervention and control groups. During the implementation period the slopes of the lines did not differ significantly between the intervention and control groups (P = 0.11). During the follow up period, the proportion of children with all services in control practices remained relatively constant, changing from 0.09 at the start of the follow up period to only 0.10 after 30 months of follow up. In contrast, the proportion of children with all services in intervention practices increased from 0.07 to 0.34 over the same time period. After baseline differences were adjusted for, the change in the prevalence of all four services between the beginning and the end of the study was 4.6-fold greater (95% confidence interval 1.6 to 13.2) in intervention practices than in control practices (table 3).
Fig 2 Proportion of children with up to date records of all four preventive services
Table 3 Effect of the intervention on primary study outcome: proportion of children with all age appropriate preventive services in intervention and control practices during follow up period
We also examined which of the preventive services were most affected by the intervention. The intervention had the greatest impact on lead, tuberculosis, and anaemia screening (figure 3). At the end of the follow up period, the proportion of children per practice who had a record of receiving each of the four individual preventive services was higher in intervention than in control practices; differences for tuberculosis (54% v 32%), lead (68% v 30%), and anaemia (79% v 71%) screening were significant (P < 0.05). For immunisation rates, the improvement over 30 months was about the same in intervention practices and control practices.
Fig 3 Proportion of children with up to date information on individual preventive services
To assess the extent to which these results were produced by differences in documentation, we compared the proportion of children receiving blood lead testing (which is indicated in only a subset of children) within the two groups and observed the same pattern of results. The proportion of children with age appropriate blood lead testing changed from 11% to 34% in intervention practices compared with 15% to 19% in control practices.
The experience of one intervention practice shows how practices used small scale plan-do-study-act cycles to develop and implement changes to delivery of preventive services. In this practice, the initial baseline data were met with scepticism. In an initial PDSA cycle, practice staff reviewed their own charts and confirmed the low rates of care. In a planning phase, the doctor leading the effort identified chart screening as an improvement to test. In another series of PDSA cycles, nurses screened charts each time the child visited the practice and placed a brightly coloured sticker on the chart to indicate which preventive services were needed. Within a few months, the doctor-nurse team concluded that the changes represented meaningful improvements. Following this success, all the nurses in the practice were asked to adopt chart screening and prompting about needed services. Doctors reported that these changes reduced the time clinicians spent reviewing the chart, increasing the time for dealing with the patient's needs and concerns. The doctor leading the effort subsequently applied the approach to redesign of the office's system of nurses giving advice on the telephone.
Discussion
Centers for Disease Control. National, state, and urban area vaccination coverage levels among children aged 19-35 months. United States, 2000. MMWR Morb Mortal Wkly Rep 2001;50: 637-41.
US Preventive Services Task Force. Guide to clinical preventive services. 3rd ed, 2000-2002. Washington, DC: Office of Disease Prevention and Health Promotion, US Government Printing Office, 2002.
American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for preventative pediatric health care. Pediatrics 2000;105: 645-6.
Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
Leininger LS, Finn L, Dickey L, Dietrich AJ, Foxhall L, Garr D, et al. An office system for organizing preventive services: a report by the American Cancer Society Advisory Group on Preventive Health Care Reminder Systems. Arch Fam Med 1996;5: 108-15.
Carey TS, Kinsinger L, Keyserling T, Harris R. Research in the community: recruiting and retaining practices. J Community Health 1996;21: 315-27.
US Department of Health and Human Services, Public Health Service. Child health guide: put prevention into practice. Washington, DC: Department of Health and Human Services, Public Health Services, 1998. (Publication No APPIP 98-0026.)
Davis D, Evans M, Jadad A, Perrier L, Rath D, Ryan D, et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ 2003;327: 33-5.
Bordley WC, Margolis PA, Stuart J, Lannon C, Keyes L. Improving preventive service delivery through office systems. Pediatrics 2001;108: e41.
Langley GK, Nolan T, Nolan C, Norman, Provost L. The improvement guide: a practical approach to enhancing organizational performance. San Francisco: Jossey-Bass, 1996.
Soumerai SB, Avorn J. Principles of educational outreach (`academic detailing') to improve clinical decision making. JAMA 1990;263: 549-56.
Szilagyi PG, Bordley C, Vann JC, Chelminski A, Kraus RM, Margolis PA, et al. Effect of patient reminder/recall interventions on immunization rates: a review. JAMA 2000;284: 1820-7.
Hulscher ME, Wensing M, Grol RP, van der Weijden T, van Weel C. Interventions to improve the delivery of preventive services in primary care. Am J Public Health 1999;89: 737-46.
Norman EH, Bordley WC, Hertz-Picciotto I, Newton DA. Rural-urban blood lead differences in North Carolina children. Pediatrics 1994;1: 59-64.
Kish L. Survey sampling. New York: Wiley, 1965: 148-81.
Vonesh EF, Chinchilli VM. Linear and nonlinear models for the analysis of repeated measurements. New York: Dekker, 1997: 381-443.
Davis DA, Mazmanian PE. Continuing medical education and the physician as a learner: guide to the evidence. JAMA 2002;288: 1057-60.
Dietrich AJ, O'Connor GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention: a community practice randomized trial. BMJ 1992;304: 687-91.
Dietrich AJ, Tobin JN, Sox CH, Cassels AN, Negron F, Younge RG, et al. Cancer early-detection services in community health centers for the undeserved. A randomized controlled trial. Arch Fam Med 1998;7: 320-7.
Solberg LI, Kottke TE, Brekke ML, Magnan S, Davidson G, Calomeni CA, et al. Failure of a continuous quality improvement intervention to increase the delivery of preventive services. A randomized trial. Effective Clin Pract 2000;3: 105-15.
Solberg LI, Kottke TE, Brekke M, Magnan S. Improving prevention is difficult. Effective Clin Pract 2000;3: 153-5.
Goodwin MA, Zyzanski SJ, Zronek S, Ruhe M, Weyer SM, Konrad N, et al. A clinical trial of tailored office systems for preventive service delivery. The study to enhance prevention by understanding practice (STEP-UP). Am J Prev Med 2001;21: 20-8.
Deming EW. Out of the crisis. Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study, 1977: 330.
National Partnership for Immunization. North Carolina immunization rates. www.partnersforimmunization.org/PPT/northcarolina.pdf (accessed 1 Apr 2003).
1 University of North Carolina at Chapel Hill, North Carolina Center for Children's Healthcare Improvement, 730 Airport Rd, Ste 104, CB#7226, Chapel Hill, NC 27599, USA, 2 University of North Carolina at Chapel Hill, School of Public Health, Department of Health Policy and Administration, Chapel Hill, 3 Rho Inc, Chapel Hill, NC 27514, USA, 4 Vanderbilt University School of Medicine, Nashville, TN 37232, USA
Correspondence to: P A Margolis Peter_Margolis@med.unc.edu
Abstract
Preventive services are the cornerstone of primary care for children. Yet only about 75% of 2 year olds are fully immunised,1 and rates of preventive services such as screening for anaemia, tuberculosis, lead, and vision defects are disappointingly low. The large number of age specific preventive services recommended in the first five years of life2 3 and the time constraints under which primary care physicians practise make it easy for clinicians to overlook opportunities for preventive care.
The challenge of achieving more reliable delivery of preventive services highlights the need for a more systematic approach.4 Recent studies have shown that better "office systems" can improve the delivery of preventive care.5 Office systems are defined as an organised series of interrelated activities carried out by several members of staff to achieve a specific purpose (for example, billing). Office systems for prevention are focused on interactions of patients, staff, and clinicians, ensuring that each step of the process of preventive care is carried out for every eligible patient at every encounter. The primary hypothesis for our study was that practices that received continuing medical education (CME) in combination with process improvement methods to implement office systems would have higher rates of four core preventive services than practices that did not.
Methods
Practices and characteristics
Of the practices screened for eligibility, 88 met the inclusion criteria (figure 1). After contact for recruitment, 24 were found ineligible. Eligible practices were stratified into blocks and recruited until the target number of practices was achieved. Of the 59 practices recruited, 44 (75%) agreed to be randomised. In the intervention group, one did not participate in the intervention and three dropped out after they went bankrupt. In the control group, one practice went bankrupt during the study and dropped out.
Fig 1 Recruitment process. *The five practices "not asked to participate" were not selected for recruitment because the target sample size had been achieved
Randomisation produced intervention and control practices with comparable baseline rates of preventive services (table 1) and practice characteristics (table 2). Control practices were twice as likely to be physician owned. Only about 11% of children across all practices had all four preventive services documented in their charts; lead and tuberculosis screening were particularly low.
Table 1 Mean (SD) percentage of patients with age appropriate preventive services in intervention and control practices at baseline.
Table 2 Characteristics of participating practices at baseline. Unless indicated otherwise, values are mean (minimum, maximum)
Implementation of intervention
Practices in the intervention group were followed for an average of 24 months after the beginning of the intervention. During the implementation period, all intervention practices developed improvement teams. Project teams met with practice improvement teams a median 8.5 times (range 5-14 times). Of the 22 intervention practices, 18 (82%) implemented preventive services summaries in patient charts, 17 (77%) used tools to support risk assessments, 15 (68%) used prompting by clinicians, and 7 (32%) instituted new health maintenance records for well child visits.
Effectiveness of intervention
Figure 2 shows the pattern of change over time in the proportion of children per practice with all four preventive services in intervention and control groups. During the implementation period the slopes of the lines did not differ significantly between the intervention and control groups (P = 0.11). During the follow up period, the proportion of children with all services in control practices remained relatively constant, changing from 0.09 at the start of the follow up period to only 0.10 after 30 months of follow up. In contrast, the proportion of children with all services in intervention practices increased from 0.07 to 0.34 over the same time period. After baseline differences were adjusted for, the change in the prevalence of all four services between the beginning and the end of the study was 4.6-fold greater (95% confidence interval 1.6 to 13.2) in intervention practices than in control practices (table 3).
Fig 2 Proportion of children with up to date records of all four preventive services
Table 3 Effect of the intervention on primary study outcome: proportion of children with all age appropriate preventive services in intervention and control practices during follow up period
We also examined which of the preventive services were most affected by the intervention. The intervention had the greatest impact on lead, tuberculosis, and anaemia screening (figure 3). At the end of the follow up period, the proportion of children per practice who had a record of receiving each of the four individual preventive services was higher in intervention than in control practices; differences for tuberculosis (54% v 32%), lead (68% v 30%), and anaemia (79% v 71%) screening were significant (P < 0.05). For immunisation rates, the improvement over 30 months was about the same in intervention practices and control practices.
Fig 3 Proportion of children with up to date information on individual preventive services
To assess the extent to which these results were produced by differences in documentation, we compared the proportion of children receiving blood lead testing (which is indicated in only a subset of children) within the two groups and observed the same pattern of results. The proportion of children with age appropriate blood lead testing changed from 11% to 34% in intervention practices compared with 15% to 19% in control practices.
The experience of one intervention practice shows how practices used small scale plan-do-study-act cycles to develop and implement changes to delivery of preventive services. In this practice, the initial baseline data were met with scepticism. In an initial PDSA cycle, practice staff reviewed their own charts and confirmed the low rates of care. In a planning phase, the doctor leading the effort identified chart screening as an improvement to test. In another series of PDSA cycles, nurses screened charts each time the child visited the practice and placed a brightly coloured sticker on the chart to indicate which preventive services were needed. Within a few months, the doctor-nurse team concluded that the changes represented meaningful improvements. Following this success, all the nurses in the practice were asked to adopt chart screening and prompting about needed services. Doctors reported that these changes reduced the time clinicians spent reviewing the chart, increasing the time for dealing with the patient's needs and concerns. The doctor leading the effort subsequently applied the approach to redesign of the office's system of nurses giving advice on the telephone.
Discussion
Centers for Disease Control. National, state, and urban area vaccination coverage levels among children aged 19-35 months. United States, 2000. MMWR Morb Mortal Wkly Rep 2001;50: 637-41.
US Preventive Services Task Force. Guide to clinical preventive services. 3rd ed, 2000-2002. Washington, DC: Office of Disease Prevention and Health Promotion, US Government Printing Office, 2002.
American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for preventative pediatric health care. Pediatrics 2000;105: 645-6.
Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.
Leininger LS, Finn L, Dickey L, Dietrich AJ, Foxhall L, Garr D, et al. An office system for organizing preventive services: a report by the American Cancer Society Advisory Group on Preventive Health Care Reminder Systems. Arch Fam Med 1996;5: 108-15.
Carey TS, Kinsinger L, Keyserling T, Harris R. Research in the community: recruiting and retaining practices. J Community Health 1996;21: 315-27.
US Department of Health and Human Services, Public Health Service. Child health guide: put prevention into practice. Washington, DC: Department of Health and Human Services, Public Health Services, 1998. (Publication No APPIP 98-0026.)
Davis D, Evans M, Jadad A, Perrier L, Rath D, Ryan D, et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ 2003;327: 33-5.
Bordley WC, Margolis PA, Stuart J, Lannon C, Keyes L. Improving preventive service delivery through office systems. Pediatrics 2001;108: e41.
Langley GK, Nolan T, Nolan C, Norman, Provost L. The improvement guide: a practical approach to enhancing organizational performance. San Francisco: Jossey-Bass, 1996.
Soumerai SB, Avorn J. Principles of educational outreach (`academic detailing') to improve clinical decision making. JAMA 1990;263: 549-56.
Szilagyi PG, Bordley C, Vann JC, Chelminski A, Kraus RM, Margolis PA, et al. Effect of patient reminder/recall interventions on immunization rates: a review. JAMA 2000;284: 1820-7.
Hulscher ME, Wensing M, Grol RP, van der Weijden T, van Weel C. Interventions to improve the delivery of preventive services in primary care. Am J Public Health 1999;89: 737-46.
Norman EH, Bordley WC, Hertz-Picciotto I, Newton DA. Rural-urban blood lead differences in North Carolina children. Pediatrics 1994;1: 59-64.
Kish L. Survey sampling. New York: Wiley, 1965: 148-81.
Vonesh EF, Chinchilli VM. Linear and nonlinear models for the analysis of repeated measurements. New York: Dekker, 1997: 381-443.
Davis DA, Mazmanian PE. Continuing medical education and the physician as a learner: guide to the evidence. JAMA 2002;288: 1057-60.
Dietrich AJ, O'Connor GT, Keller A, Carney PA, Levy D, Whaley FS. Cancer: improving early detection and prevention: a community practice randomized trial. BMJ 1992;304: 687-91.
Dietrich AJ, Tobin JN, Sox CH, Cassels AN, Negron F, Younge RG, et al. Cancer early-detection services in community health centers for the undeserved. A randomized controlled trial. Arch Fam Med 1998;7: 320-7.
Solberg LI, Kottke TE, Brekke ML, Magnan S, Davidson G, Calomeni CA, et al. Failure of a continuous quality improvement intervention to increase the delivery of preventive services. A randomized trial. Effective Clin Pract 2000;3: 105-15.
Solberg LI, Kottke TE, Brekke M, Magnan S. Improving prevention is difficult. Effective Clin Pract 2000;3: 153-5.
Goodwin MA, Zyzanski SJ, Zronek S, Ruhe M, Weyer SM, Konrad N, et al. A clinical trial of tailored office systems for preventive service delivery. The study to enhance prevention by understanding practice (STEP-UP). Am J Prev Med 2001;21: 20-8.
Deming EW. Out of the crisis. Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Study, 1977: 330.
National Partnership for Immunization. North Carolina immunization rates. www.partnersforimmunization.org/PPT/northcarolina.pdf (accessed 1 Apr 2003).