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Research ArticleOriginal Research

Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

W. Perry Dickinson, L. Miriam Dickinson, Paul A. Nutting, Caroline B. Emsermann, Brandon Tutt, Benjamin F. Crabtree, Lawrence Fisher, Marjie Harbrecht, Allyson Gottsman and David R. West
The Annals of Family Medicine January 2014, 12 (1) 8-16; DOI: https://doi.org/10.1370/afm.1591
W. Perry Dickinson
1Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
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  • For correspondence: perry.dickinson@ucdenver.edu
L. Miriam Dickinson
1Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Paul A. Nutting
1Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Caroline B. Emsermann
2Clinical Research Strategies, Denver, Colorado
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Brandon Tutt
1Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Benjamin F. Crabtree
3Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Lawrence Fisher
4Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California
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Marjie Harbrecht
5Health TeamWorks, Lakewood, Colorado
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Allyson Gottsman
5Health TeamWorks, Lakewood, Colorado
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David R. West
1Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
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    Figure 1

    CONSORT diagram.

    CONSORT = Consolidated Standards of Reporting Trials; CQI = continuous quality improvement; RAP = reflective adaptive process; SD = self-directed.

    Notes: 2 RAP practices and 2 CQI practices had limited or no active participation after baseline. Clinicians surveyed using the Assessment of Clinician Diabetes Management included all physicians, nurse practitioners, and physician assistants. Clinicians and staff surveyed using the Practice Culture Assessment included everyone in any role in the practice.

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    Table 1

    Baseline Practice and Patient Characteristics

    CharacteristicRAPCQISD
    Practices(n = 15)(n = 10)(n = 15)
    Rural, No. (%)4 (27)2 (20)4 (27)
    Practice size (office visits per week), No. (%)
     Large (>400)3 (20)1 (10)3 (33)
     Medium (91–400)10 (67)4 (40)10 (47)
     Small (1–90)2 (13)5 (50)2 (20)
    Patients on Medicaid, %
     <5%8 (53)4 (40)6 (40)
     5%–20%3 (20)4 (40)4 (27)
     >20%4 (27)2 (20)5 (33)
    Patientsa(n = 312)(n = 189)(n = 321)
    Sex, % male44.252.950.5
    Age, mean (SD), y60.5(12.6)61.9 (12.1)60.0 (13.2)
    Medical comorbidities, mean (SD), No.b2.1 (1.2)2.0 (1.3)2.0 (1.1)
    Have psychiatric comorbidity, %c20.514.313.1
    HbA1c level, mean (SD), %d7.18 (1.59)7.35 (1.76)7.69 (2.00)
    Systolic blood pressure, mean (SD), mm Hgd128.3 (16.4)131.8 (17.7132.9 (19.7)
    Diastolic blood pressure, mean (SD), mm Hg76.9 (10.9)78.5 (12.2)78.0 (11.9)
    Total cholesterol level, mean (SD), mg/dLe174.5 (42.6)185.8 (49.3)184.8 (50.4)
    • CQI = continuous quality improvement; HbA1c = hemoglobin A1c; RAP = reflective adaptive process; SD = self-directed.

    • ↵a HbA1c levels were determined for 636 patients, systolic and diastolic blood pressure for 799 patients, and total cholesterol levels for 703 patients.

    • ↵b Arthritis, connective tissue disease, gastrointestinal problems, coronary disease, hyperlipidemia, hypertension, liver disease, pulmonary disease, neurologic disease, peripheral vascular disease, renal disease, stroke, dementia, cancer in past 3 years.

    • ↵c Depression, substance abuse, other psychiatric diagnosis.

    • ↵d P <.01.

    • ↵e P <.05.

    • View popup
    Table 2

    Diabetes Quality Measures Over Time by Group

    Quality MeasureRAPCQISDDifferential Change Over TimeP Value
    Total process of care scorea
     Baseline4.543.583.63Overall: F4,2386 = 10.70<.0001
     9 months4.694.914.04RAP × SD: F2,1838 = 3.65.03
     18 months4.854.914.39CQI × SD: F2,1475 = 9.99<.0001
    …b…c…cCQI × RAP: F2,1455 = 19.27<.0001
    HbA1c level checked, %
     Baseline85.869.977.6Overall: F4,1568 = 0.49.09
     9 months91.792.388.2RAP × SD: F2,1208 = 0.14.87
     18 months93.791.089.3CQI × SD: F2,968 = 2.98.051
    …c…c…cCQI × RAP: F2,957 = 3.35.04
    Feet checked, %
     Baseline43.534.135.1Overall: F4,1568 = 2.98.02
     9 months57.960.841.5RAP × SD: F2,1208 = 14.86.34
     18 months60.268.752.2CQI × SD: F2,968 = 4.80.009
    …c…c…cCQI × RAP: F2,957 = 3.57.03
    Blood pressure checked, %
     Baseline92.184.286.5Overall: F4,1567 = 0.34.85
     9 months99.599.698.8RAP × SD: F2,1207 = 0.03.97
     18 months99.799.199.5CQI × SD: F2,967 = 0.66.51
    …c…c…cCQI × RAP: F2,957 = 0.38.68
    Dilated eye examination, %
     Baseline16.18.56.0Overall: F4,1567 = 2.35.052
     9 months16.018.15.3RAP × SD: F2,1207 = 1.23.29
     18 months22.418.112.6CQI × SD: F2,967 = 3.39.03
    …d…c…cCQI × RAP: F2,957 = 2.66.07
    Cholesterol checked, %
     Baseline81.761.871.4Overall: F4,1567 = 6.11<.0001
     9 months78.886.479.5RAP × SD: F2,1207 = 3.64.03
     18 months79.979.581.1CQI × SD: F2,967 = 4.21.02
    ……c…cCQI × RAP: F2,957 = 11.78<.0001
    Nephropathy screening, %
     Baseline38.118.724.4Overall: F4,1567 = 2.04.09
     9 months33.127.720.2RAP × SD: F2,1207 = 0.30.74
     18 months33.626.923.8CQI × SD: F2,967 = 2.90.056
    ……d…CQI × RAP: F2,957 = 3.44.03
    Influenza vaccination, %
     Baseline27.728.718.0Overall: F4,1567 = 3.01.02
     9 months29.645.321.8RAP × SD: F2,1207 = 3.96.02
     18 months25.944.330.0CQI × SD: F2,967 = 1.52.22
    ……c…cCQI × RAP: F2,957 = 3.30.04
    Nutrition counseling, %
     Baseline38.016.721.3Overall: F5,1567 = 2.61.03
     9 months32.426.124.1RAP × SD: F2,1207 = 1.62.19
     18 months38.129.620.8CQI × SD: F2,967 = 2.76.06
    ……b…CQI × RAP: F2,957 = 3.86.02
    Self-management support, %
     Baseline20.422.212.9Overall: F4,1567 = 1.09.36
     9 months18.824.414.2RAP × SD: F2,1207 = 1.57.21
     18 months21.424.221.0CQI × SD: F2,967 = 1.35.26
    ………bCQI × RAP: F2,957 = 0.23.79
    • CQI = Continuous Quality Improvement; HbA1c = hemoglobin A1c; RAP = Reflective Adaptive Process; SD = self-directed.

    • Note: Data are from chart audits. All measures pertain to whether care was provided in past 12 months.

    • ↵a Possible scores ranged from 0 to 9, with higher scores indicating better quality of diabetes care.

    • ↵b P <.05 within-group change.

    • ↵c P <.01 within-group change.

    • ↵d P <.10 within-group change.

    • View popup
    Table 3

    Practice Culture Assessment Factor Loadings for Individual Items, by Subscale

    ItemChange CultureWork CultureChaos
    After making a change, we discuss what worked and what didn’t.0.66398……
    This practice puts a great deal of effort into improving the quality of care.0.67917……
    This practice encourages everybody’s input for making changes.0.81108……
    We regularly take time to consider ways to improve how we do things.0.79724……
    The practice leadership makes sure that we have the time and space necessary to discuss changes to improve care.0.78396……
    This practice uses data and information to improve the work of the practice.0.62714……
    Our practice encourages people to share their ideas about how to improve things.0.79928……
    The leadership in this practice is available to discuss work related problems0.72885……
    When we experience a problem in the practice we make a serious effort to figure out what’s really going on.0.72684……
    The leadership of this practice is good at helping us to make sense of problems or difficult situations.0.74846……
    My opinion is valued by others in this practice.…0.69821…
    People in this practice understand how their jobs fit into the rest of the practice.…0.65733…
    I can rely on the other people in this practice to do their jobs well.…0.73350…
    When there is conflict or tension in this practice, those involved are encouraged to talk about it.…0.67104…
    People in this practice are thoughtful about how they do their jobs…0.77181…
    People in this practice pay attention to how their actions affect others in the practice.…0.74617…
    Most of the people who work in our practice seem enjoy their work.…0.76567…
    The practice leadership promotes an environment that is an enjoyable place to work.…0.76768…
    This practice is almost always in chaos.……0.71993
    This practice is very disorganized.……0.73899
    Our practice has recently been very stable.……−0.67600
    Things have been changing so fast in our practice that it is hard to keep up with what is going on.……0.58880
    • View popup
    Table 4

    Practice Culture Assessment Scores Over Time by Group

    SubscaleRAPCQISDDifferential Change Over TimeP Value
    Change Culture
     Baseline66.269.567.1Overall: F4,66 = 1.91.12
     9 months68.568.566.6RAP × SD: F2,52 = 3.33.04
     18 months64.067.366.9CQI × SD: F2,42 = 0.51.60
    …a……CQI × RAP: F2,38 = 1.75.19
    Chaos
     Baseline47.743.449.0Overall: F4,66 = 3.47.01
     9 months50.246.850.0RAP × SD: F2,52 = 3.87.03
     18 months50.848.247.3CQI × SD: F2,42 = 5.63.007
    …b…b…CQI × RAP: F2,38 = 0.49.62
    Work Culture
     Baseline69.868.766.5Overall: F4,66 = 2.34.06
     9 months68.869.268.1RAP × SD: F2,52 = 4.59.01
     18 months66.468.668.5CQI × SD: F2,42 = 0.49.62
    …b……CQI × RAP: F2,38 = 1. 59.22
    • CQI = continuous quality improvement; RAP = reflective adaptive process; SD = self-directed.

    • Note: Scores are means.

    • ↵a P <.01 within-group change.

    • ↵b P <.05 within-group change.

Additional Files

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  • The Article in Brief

    Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

    W. Perry Dickinson , and colleagues

    Background Many practice redesign efforts focus on implementing the Chronic Care Model, which summarizes basic elements for improving care in health systems at the community, organization, practice and patient levels. The current study compares the effectiveness of three different Chronic Care Model-based approaches to improve diabetes care in primary care. The three approaches are 1) Continuous Quality Improvement (CQI) in which practices follow a strategy of implementing registries to have diabetes quality measures motivate practice action, identify needed changes, and monitor progress; 2) Reflective Adaptive Process (RAP) in which practices follow a more practice-determined approach for improving practice culture; and 3) Self-Directed (SD) in which practices are given information and resources about the Chronic Care Model and quality improvement but without the assistance of a facilitator.

    What This Study Found All methods resulted in significant improvement in diabetes care measures, but there were differences in the extent and duration of improvement and trade-offs in work culture change. Although measures of the quality of diabetes care improved in all three groups, improvement was greater in CQI practices compared with both SD and RAP practices, and greater in SD practices compared with RAP practices. In RAP practices, change culture scores showed a trend toward improvement at nine months, but decreased below baseline at 18 months, and work culture scores decreased from nine to 18 months. Both scores were stable over time in SD and CQI practices.

    Implications

    • Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice culture.
    • Short-term practice facilitation based on RAP principles appears to be less effective at improving quality measures and does not produce sustained improvements in practice culture.
    • Recognizing that not all primary care practices need the same type, intensity, or duration of assistance, the authors call for practices to tailor the approach to their practice. They also call for the development and testing of new models that can produce the long-term improvements in both quality measures and practice cultures necessary for sustained care enhancement.
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Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial
W. Perry Dickinson, L. Miriam Dickinson, Paul A. Nutting, Caroline B. Emsermann, Brandon Tutt, Benjamin F. Crabtree, Lawrence Fisher, Marjie Harbrecht, Allyson Gottsman, David R. West
The Annals of Family Medicine Jan 2014, 12 (1) 8-16; DOI: 10.1370/afm.1591

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Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial
W. Perry Dickinson, L. Miriam Dickinson, Paul A. Nutting, Caroline B. Emsermann, Brandon Tutt, Benjamin F. Crabtree, Lawrence Fisher, Marjie Harbrecht, Allyson Gottsman, David R. West
The Annals of Family Medicine Jan 2014, 12 (1) 8-16; DOI: 10.1370/afm.1591
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