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Research ArticleOriginal Research

Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial

James W. Mold, Chester Fox, Angela Wisniewski, Paula Darby Lipman, Margot R. Krauss, D. Robert Harris, Cheryl Aspy, Rachel A. Cohen, Kurt Elward, Paul Frame, Barbara P. Yawn, Leif I. Solberg and René Gonin
The Annals of Family Medicine May 2014, 12 (3) 233-240; DOI: https://doi.org/10.1370/afm.1624
James W. Mold
1University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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  • For correspondence: james-mold@ouhsc.edu
Chester Fox
4New York State University, Buffalo, New York
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Angela Wisniewski
4New York State University, Buffalo, New York
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Paula Darby Lipman
2Westat, Rockville, Maryland
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Margot R. Krauss
2Westat, Rockville, Maryland
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D. Robert Harris
2Westat, Rockville, Maryland
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Cheryl Aspy
1University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Rachel A. Cohen
2Westat, Rockville, Maryland
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Kurt Elward
3University of Virginia, Charlottesville, Virginia
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Paul Frame
53131 Avon Rd, Geneseo, New York
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Barbara P. Yawn
6Olmsted Medical Center, Rochester, Minnesota
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Leif I. Solberg
7Health Partners, Minneapolis, Minnesota
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René Gonin
2Westat, Rockville, Maryland
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Article Figures & Data

Tables

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    Table 1

    Practice Characteristics by Study Arm

    Practice CharacteristicLLCPFPF + LLCControlP Valuea
    Participating practices, No.10101211NA
    Medical record type, No. (%)
     Electronic health record4 (40)8 (80)9 (75)5 (45).14
     Paper6 (60)2 (20)3 (25)6 (55)
    Mid-level practitioners, No. (%)
     Yes6 (60)6 (60)9 (75)6 (55).76
     No4 (40)4 (40)3 (25)5 (45)
    Practice size, No. (%)
     13 (30)2 (20)2 (17)2 (18).67
     22 (20)2 (20)3 (25)2 (18)
     3–54 (40)1 (10)3 (25)5 (45)
     ≥61 (10)5 (50)4 (33)2 (18)
    Clinician owned, No. (%)
     Yes6 (60)5 (50)5 (42)4 (36).72
     No4 (40)5 (50)7 (58)7 (64)
    • LLC = local learning collaborative; PF = practice facilitation.

    • ↵a P values were obtained from the Fisher exact test of the Fisher-Freman-Halton exact test.

    • View popup
    Table 2

    Unadjusted Analyses of Guideline Implementation for the Overall Study Population

    Study Population of InterestOutcome MeasureMatched Pairs No.Preintervention %Postintervention %Change %P Valuea
    All asthmatic patientsAssessment of asthma severity977375619<.001
    Assessment of environmental triggers1,016385214<.001
    Asthma action plan9837114.002
    At each asthma visitAssessment of level of control937405616<.001
    All patients with persistent asthmaAsthma controller medications86782875.002
    Primary asthma visitAsthma follow-up visits41072797.002
    • ↵a Obtained from McNemar test.

    • View popup
    Table 3

    Unadjusted Analyses of Guideline Implementation by Study Arm of Matched Pairs

    Study Population of InterestOutcome MeasureControlPFLLCPF + LLC
    No.Pre %Post %No.Pre %Post %No.Pre %Post %No.Pre %Post %
    All asthmatic patientsAssessment of asthma severity1884556a2834271a1962839a3103352a
    Assessment of environmental triggers1925870a2904257a20217243323654a
    Asthma action plan180131528271019938b322711
    At each asthma visitAssessment of level of control17244452765573a2762445a3013454a
    All patients with persistent asthmaAsthma controller medications153798025484871887887b2898491b
    Primary asthma visitAsthma follow-up visits66627011178837865721557484b
    • LLC = local learning collaborative; PF = practice facilitation; post = postintervention; pre = preintervention.

    • ↵a Significantly improved by matched pairs (McNemar test), P <.01.

    • ↵b Significantly improved by matched pairs (McNemar test), P <.05.

    • View popup
    Table 4

    Multivariable Modeling of the Pre- to Postintervention Change in the Outcome Measures by Study Arm

    VariableAssessment of Asthma Severity OR (95% CI)Assessment of Environmental Triggers OR (95% CI)Asthma Action Plan OR (95% CI)Assessment of Level of Contro OR (95% CI)Asthma Controller Medications OR (95% CI)Asthma Follow-up Visits OR (95% CI)
    Interaction of study arm with study period
     LLC0.5 (0.3–0.7)……0.8 (0.5–1.2)……
     PF2.5 (1.7–3.8)……2.3 (1.5–3.5)……
     PF + LLC1.0 (0.7–1.5)……1.1 (0.7–1.7)……
     Control1.0……1.0……
    P value.002.58. 24.005.24.83
    Medical record type
     Electronic0.6 (0.5,−0.8)1.6 (1.1–2.2)0.6 (0.4–0.9)
     Paper1.01.01.0
    P value<.001.005.020………
    Mid-level practitioners
     Yes1.8 (1.3–2.4)…0.5 (0.3, 0.9)………
     No1.0…1.0……
    P value<.001….011………
    Practice size
     1…0.7 (0.4–1.1)0.3 (0.1–0.8)1.0 (0.7–1.5)…1.5 (0.7–3.2)
     2…1.9 (1.4–2.6)1.5 (0.9–2.4)1.5 (1.2–2.0)…3.0 (1.6–5.5)
     3–5…1.6 (1.1–2.4)0.9 (0.5–1.7)0.8 (0.6–1.1)…1.2 (0.7–2.1)
     ≥6…1.01.01. 0…1.0
    P value…<.0 01<.0 01<. 0 01….001
    Clinician owned
     Yes…1.6 (1.3–2.1)…1.5 (1.2–1.9)…0.3 (0.2–0.5)
     No…1.0…1.0…1.0
    P value…<.001…<.001…<.001
    Region
     New York0.6 (0.5–0.8)1.3 (1.0–1.6)0.2 (0.2–0.4)1.5 (1.2–1.9)0.7 (0.5–0.9)1.9 (1.3–3.0)
     Oklahoma1.01.01.01.01.01.0
    P value<.001.038<.001<.001.006.004
    • LLC = local learning collaborative; OR = odds ratio; PF = practice facilitation.

Additional Files

  • Tables
  • Supplemental Appendix

    Supplemental Appendix: Pre- to Postintervention Change in Proportion of Patients where the Guidelines were Implemented by Practice

    Files in this Data Supplement:

    • Supplemental data: Appendix - PDF file
  • The Article in Brief

    Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial

    James W. Mold , and colleagues

    Background Implementing clinical practice guidelines for managing chronic diseases can be challenging for primary care practices. Two promising types of assistance are practice facilitation (PF) and learning collaboratives. This study compares the effectiveness of these two interventions, along with performance feedback and education (academic detailing) on practices' success in implementing the National Heart, Lung and Blood Institute's Asthma Guidelines.

    What This Study Found Practice facilitation appears to be better than education, practical tools and performance feedback alone in helping primary care practices implement asthma guidelines. The intensity of the intervention appears to correlate with effectiveness.

    Implications

    • These findings may help efforts to improve guideline implementation in primary care practices.
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The Annals of Family Medicine: 12 (3)
The Annals of Family Medicine: 12 (3)
Vol. 12, Issue 3
May/June 2014
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Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial
James W. Mold, Chester Fox, Angela Wisniewski, Paula Darby Lipman, Margot R. Krauss, D. Robert Harris, Cheryl Aspy, Rachel A. Cohen, Kurt Elward, Paul Frame, Barbara P. Yawn, Leif I. Solberg, René Gonin
The Annals of Family Medicine May 2014, 12 (3) 233-240; DOI: 10.1370/afm.1624

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Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial
James W. Mold, Chester Fox, Angela Wisniewski, Paula Darby Lipman, Margot R. Krauss, D. Robert Harris, Cheryl Aspy, Rachel A. Cohen, Kurt Elward, Paul Frame, Barbara P. Yawn, Leif I. Solberg, René Gonin
The Annals of Family Medicine May 2014, 12 (3) 233-240; DOI: 10.1370/afm.1624
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