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Research ArticleOriginal ResearchA

Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study

Kamal H. Henderson, Darren A. DeWalt, Jacquie Halladay, Bryan J. Weiner, Jung I. Kim, Jason Fine and Samuel Cykert
The Annals of Family Medicine April 2018, 16 (Suppl 1) S29-S34; DOI: https://doi.org/10.1370/afm.2210
Kamal H. Henderson
1Division of Cardiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
2Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
MD
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Darren A. DeWalt
3Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
4Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
MD, MPH
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Jacquie Halladay
2Division of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
4Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
MD, MPH
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Bryan J. Weiner
5Departments of Global Health and Biostatistics, University of Washington, Seattle, Washington
PhD
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Jung I. Kim
6UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
PhD
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Jason Fine
6UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
ScD
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Samuel Cykert
3Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
4Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina
MD
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    Figure 1

    Predicted practice-level performance on blood pressure control measure stratified by organizational quality improvement characteristics.

    KDIS = Key Drivers of Implementation Scale; PAR =practice adaptive reserve.

    Note: Unadjusted linear regression models were used to estimate predicted proportion of hypertension control.

    aPredicted mean practice-level adequate hypertension control calculated using linear regression models.

    bNo statistical difference between mean adequate hypertension control and higher leadership quality improvement capability (P =.321).

    cNo statistical difference between mean adequate hypertension control and higher quartiles of PAR (P =.504).

Tables

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    Table 1

    Baseline Practice Characteristics on 181 Heart Health NOW Practices

    CharacteristicValuea
    Adequate hypertension control
     Patient-level, No. (%)b104,473 (61)
     Top quartile control, No. (% controlled)c46 (>68)
    Clinicians per clinic, mean No. (SD)d6.5 (8.5)
    Office staff per clinic, mean No. (SD)9.4 (18.5)
    Ownership structuree
     Physician owned, No. (%)77 (58)
     Health or hospital system ownership, No. (%)56 (42)
    Payer mixf
     Medicare, mean %29
     Medicaid, mean %16
     Commercial insurance, mean %29
     Uninsured, mean %12
    Clinician practice visits per day, mean No.21
    Practice type
     PCMH, No. (%)89 (61)
     FQHC, No. (%)34 (30)
     Rural, No. (%)19 (17)
    Staff role of survey respondentsg
     Physician, nurse practitioner, physician assistant, No. (%)98 (14)
     Nurse, medical assistant, No. (%)378 (54)
     Billing, receptionist, office manager, No. (%)218 (31)
    • FQHC = federally qualified health center; PCMH = patient-centered medical home.

    • Note: Total number of patients with hypertension among the practices = 171,570.

    • ↵a Percentages and mean numbers listed may reflect rounding.

    • ↵b Percentages represent patients that met adequate hypertension control among all the practices included in our analysis (last clinic blood pressure was <140/90 mm Hg).

    • ↵c Primary care clinics among top quartile for adult adequate hypertension control.

    • ↵d Practice size information was not available for 48 practices, and information displayed is among practices for which data were available.

    • ↵e Practice ownership was not available for 43 practices and information displayed is among practices for which data were available.

    • ↵f The total of payer mix values is 86% because 14% of the payer mix was dual or outside the payer categories described in Table 1.

    • ↵g The total of subvalue is 99% because staff were able to specify more than 1 role (n=6).

    • View popup
    Table 2

    Practice-Level Comparison of Top Quartile Hypertension Performance

    Top Quartile Hypertension
    Practice-Level CharacteristicTop Quartile Achieved
    n=46
    Top Quartile Not Achieved
    n=135
    P Value
    Clinicians, mean No. (SD)5 (5.4)5.6 (4.8).596
    Office staff, mean No. (SD)8.6 (11.4)8.3 (7.8).917
    Physician owned, No. (%)27 (35)50 (65).015
    Payer mix
     Medicare, % (SD)28 (19.2)29 (14.8).776
     Medicaid, % (SD)15 (11.6)17 (11.7).477
     Commercial insurance, % (SD)37 (15.9)26 (18.3).002
     Uninsured, % (SD)8 (9.5)14 (14.7).055
    Practice delivery model
     PCMH, No. (%)29 (33)60 (67).014
     FQHC, No. (%)5 (15)29 (85).179
    Organizational quality improvement quality
     PAR score, mean (SD)a0.72 (0.11)0.67 (0.11).165
     KDIS leadership scoreb,c
      079…
      11759…
      21442…
      3825…
    • FQHC = federally qualified health center; KDIS = Key Driver Implementation Scale; PAR = practice adaptive reserve; PCMH = patient-centered medical home; QI = quality improvement.

    • ↵a PAR scores are scaled from 0 to 1, with 1 being a perfect score of agreement for organizational adaptiveness.

    • ↵b KDIS Leadership scores are scaled from 0 to 3, with 3 being a perfect score that leadership recognizes QI work as part of the daily routine and practice culture.

    • ↵c P=.356, estimated from χ2 analysis comparing ordinal leadership scores for all practices achieving top quartile hypertension control vs not achieving top quartile hypertension control.

    • View popup
    Table 3

    Association of Practice Adaptive Reserve and Advance Leadership in Quality Improvement Capability With Target Hypertension

    Quality Improvement Contextual FactorsPR (CI)P ValueAdjusted PR (CI)aP Value
    Leadershipb
     Low leadership (score 0–1)1 [Referent]1 [Referent]
     High leadership (score 2–3)0.94 (0.57–1.56).8330.81 (0.48–1.37).429
    PAR scorec
     0.00 to <0.661 [Referent]1 [Referent]
     0.65 to <0.761.47 (0.71–3.03).2971.25 (0.52–2.99).611
     0.76 to 1.001.92 (0.9–4.1).0911.45 (0.56–3.76).440
    High leadership+PAR scoresd
     High leadership0.93 (0.57–1.53).776
     PAR (0.65 to <0.76)1.48 (0.72–3.05).289
     PAR (0.76 to 1.00)1.92 (0.9–4.09).089
    • PAR=practice adaptive reserve; PR=prevalence ratio.

    • ↵a Modified Poisson regression models adjusted for the following: proportion of commercially insured patients, practice designation as a patient-centered medical home, and clinician-owned practices

    • ↵b PR: prevalence for top quartile hypertension control among practices with high leadership support for quality improvement implementation divided by the prevalence for top quartile hypertension control among practices with less leadership support for quality improvement implementation.

    • ↵c PR: prevalence for achieving top quartile hypertension control among practices with higher quartiles of PAR divided by the prevalence for top quartile hypertension control among practices with the lowest quartile of PAR.

    • ↵d PR reflects adjustments for both high leadership support for quality improvement implementation and higher quartiles of PAR when compared to the referent (low leadership support for quality improvement implementation and lowest quartile of PAR).

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The Annals of Family Medicine: 16 (Suppl 1)
The Annals of Family Medicine: 16 (Suppl 1)
Vol. 16, Issue Suppl 1
April 2018
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Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study
Kamal H. Henderson, Darren A. DeWalt, Jacquie Halladay, Bryan J. Weiner, Jung I. Kim, Jason Fine, Samuel Cykert
The Annals of Family Medicine Apr 2018, 16 (Suppl 1) S29-S34; DOI: 10.1370/afm.2210

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Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study
Kamal H. Henderson, Darren A. DeWalt, Jacquie Halladay, Bryan J. Weiner, Jung I. Kim, Jason Fine, Samuel Cykert
The Annals of Family Medicine Apr 2018, 16 (Suppl 1) S29-S34; DOI: 10.1370/afm.2210
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Subjects

  • Methods:
    • Quantitative methods
  • Other topics:
    • Quality improvement

Keywords

  • blood pressure control
  • quality improvement
  • primary health care
  • hypertension
  • leadership
  • population health
  • cardiovascular disease

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