Article Figures & Data
Figures
- Figure 1
Framework for sustainable practice transformation.
CME = continuing medical education; IT = information technology; MOC = maintenance of certification; QI = quality improvement.
- Figure 2
Representation of level of quality over time for transformed practices, activated practices, and engaged practices over 2 years.
Tables
Characteristic Value Practices, No. 18 Service area, % Rural 33 Urban 67 Quality focus, % Diabetes 72 Asthma 28 Patients served, No. Diabetes 23,500 Asthma 4,700 Size, % ≥5 Physicians 56 <5 Physicians 44 Practice type, % Private 39 Community health center/health department 34 Academic 27 Data extraction capability, % Convenience 17 Random 44 Total population 33 Not extracting data 6 Practice specialty, % Family medicine 56 Pediatric medicine 28 Internal medicine 16 Clinical Measuresa Practice Measures (All Practices) Diabetes improvement over 12 months Practice type Hemoglobin A1c >9% Rural/urban Blood pressure ≤130/80 mm Hg Number of physicians Low-density cholesterol ≤100 mg/dL Specialty Additional measures included: hemoglobin A1c ≤7%, blood pressure ≤140/90 mm Hg, referral for annual eye examination, annual eye examination obtained, annual influenza shot, annual foot examination, low-density cholesterol ≤130 mg/dL, low-density cholesterol measured in past year, annual microalbumin measurement, tobacco counseling, aspirin use Use of electronic health record
Data extraction capability
Prior quality improvement experience
Quality improvement consultant ratings: engagement, leadership, registry use, template use, protocol uses, self-management supportAsthma improvement over 12 months Asthma control assessed Use of asthma controller medications Influenza vaccine Bundled patient measure of the 3 asthma measures Additional measures included: presence of action plan, tobacco counseling, emergency department use, hospitalization -
↵a Practices chose diabetes or asthma measures.
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Transformed n=7a Activated n=4 Engaged n=7 Quality focus Diabetes 5 4 4 Asthma 2 0 3 Practice type Private 3 1 3 Community health center/health department 3 2 1 Academic 1 1 3 Practice size <5 Physicians 5 1 3 ≥5 Physicians 2 3 4 Location Rural 4 2 2 Urban 3 2 5 Data extraction capability Electronic, total population 3 1 3 Electronic, incremental 1 1 2 Random chart audit 3 2 2 Clinical measures improved at 1 year,b mean (range), No. Diabetes, 14 measures 6 (4–9) 5 (5–7) 4 (4–5) Asthma, 8 measures 5 (4–7) - 1 (0–6) Clinical measures sustained or improved at year 2, mean (range), No. Diabetes, 14 measures 6 (3–9) 6 (5–7) 4 (0–7) Asthma, 8 measures 6 (5–7) – 1 (0–3)
The Article in Brief
Natural History of Practice Transformation: Development and Initial Testing of an Outcomes-Based Model
Katrina E. Donahue , and colleagues
Background Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. This study set out to develop and test a model of the natural history of practice transformation among 18 primary care practices in North Carolina during a 2-year period.
What This Study Found This study identifies three trajectories of transformation that practices can follow--transformed, activated and engaged--as well as factors affecting practices' engagement in change efforts, the rate of quality improvement ,and sustainability. According to the model, transformed practices experience robust, broad-based improvement, have highly engaged leadership, and use data to drive decisions. Activated practices experience moderate change on a slower improvement trajectory, usually encountering one or more barriers that take time to overcome. Engaged practices do not improve or are unable to sustain change because of multiple competing distractions that interfere with practice transformation.
Implications
- Internal and external practice motivations (eg, improved reimbursement, office efficiencies, better patient outcomes, institutional leadership, pay-for-performance programs, and clinician comparisons) and specific supports (eg, IT support, practice facilitators, continuing medical education, and learning sessions) affect engagement, rate of quality improvement, and long-term sustainability of transformation efforts.
- Early successes play a key role as practices learn how to change their performance.
- Practice transformation is a medium- to long-term process that varies by practice capacity, leadership, community context, and support.
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