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Research ArticleOriginal Research

Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices

Bijal A. Balasubramanian, Miguel Marino, Deborah J. Cohen, Rikki L. Ward, Alex Preston, Rachel J. Springer, Stephan R. Lindner, Samuel Edwards, K. John McConnell, Benjamin F. Crabtree, William L. Miller, Kurt C. Stange and Leif I. Solberg
The Annals of Family Medicine April 2018, 16 (Suppl 1) S35-S43; DOI: https://doi.org/10.1370/afm.2172
Bijal A. Balasubramanian
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Miguel Marino
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Deborah J. Cohen
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Rikki L. Ward
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Alex Preston
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Rachel J. Springer
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Stephan R. Lindner
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Samuel Edwards
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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K. John McConnell
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Benjamin F. Crabtree
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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William L. Miller
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Kurt C. Stange
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Leif I. Solberg
Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University – Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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    Figure 1

    Distribution of the CPCQ strategies scores among 1,181 EvidenceNOW practices.

    CPCQ = Change Process Capability Questionnaire.

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    Table 1

    Characteristics of Participating EvidenceNOW Study Practices (N = 1,181)

    CharacteristicNo. (%)
    Practice factor
    Practice size
     Solo practice241 (20.4)
     2–5 clinicians558 (47.2)
     6–10 clinicians174 (14.7)
     ≥11 clinicians143 (12.1)
    Practice ownership
     Clinician owned436 (36.9)
     Hospital, health system275 (23.3)
     FQHC, RHC, IHS, federala286 (24.2)
     Other, noneb133 (11.3)
    Locationc
     Urban core733 (62.1)
     Large town171 (14.5)
     Rural area191 (16.2)
     Suburban86 (7.3)
    Medically underserved area classification410 (34.7)
    External factor
    Received external incentives in prior 12 mo602 (51.0)
    Participation in other demonstration projects4369 (31.2)
    Patient-centered medical home recognition481 (40.7)
    Part of an accountable care organization452 (38.3)
    Internal factor
    Major disruption(s) in prior 12 mo5
     No major disruption433 (36.7)
     One major disruption412 (34.9)
     More than one major disruption246 (20.8)
    Health information technology characteristics
    Completely electronic health record61,030 (87.2)
    Time on EHR
     ≤3 y324 (27.4)
     4–6 y344 (29.1)
     >6 y365 (30.9)
    ONC-certified EHR972 (82.3)
    Participation in Meaningful Use
     Not participating189 (16.0)
     Stage 1 only139 (11.8)
     Stage 1 and stage 2722 (61.1)
    Physical location of data
     Server in practice436 (36.9)
     In cloud with vendor246 (20.8)
     Health system data warehouse229 (19.4)
     Do not know where data reside111 (9.4)
    Shares patient health information electronically762 (64.5)
    Clinical laboratories incorporated as structured data965 (81.7)
    Use of EHR data for quality improvement, reporting
    Produced quality report(s) in prior 6 mo741 (62.7)
    Report CQMs
     Practice level867 (73.4)
     Clinician level881 (74.6)
    EHR vendor helps produce CQM reports
     Yes, with restrictions226 (19.1)
     Yes, with no restrictions287 (24.3)
     No163 (13.8)
     Do not know211 (17.9)
    Outside organization helps EHR data capture731 (61.9)
    Ability to create CQM reports
     No ability206 (17.4)
     In-house clinician or other staff member writes reports305 (25.8)
     Outside service/consultant writes reports438 (37.1)
    Routinely discuss clinical quality data
     Never115 (9.7)
     Infrequently294 (24.9)
     Often425 (36.0)
     Not applicable, solo practice83 (7.0)
     Do not know98 (8.3)
    Use of at least 1 registry781 (66.1)
    Guidelines for CVD9 prevention
     Not used or clinician agreement to use390 (33.0)
     Included in EHR prompts or standing orders719 (60.9)
    Guidelines for CVD management
     Not used or clinician agreement to use436 (36.9)
     Included in EHR prompts or standing orders673 (57.0)
    • CPCQ = Change Process Capability Questionnaire, CQM = clinical quality measure, CVD = cardiovascular disease, EHR = electronic health record, FQHC = federally qualified health center, IHS = Indian Health Services clinic, ONC = Office of the National Coordinator for Health Information Technology, RHC = rural health clinic.

    • Note: Percentages may not add up to 100% because of missing data. Only practices with complete CPCQ strategies scores are included. Additional characteristics of the practices involved in EvidenceNOW are located in the Supplemental Appendix, at http://www.annfammed.org/content/16/Suppl_1/S35/suppl/DC1/.

    • ↵a Federally qualified health centers, rural health clinics, Indian Health Services clinics and Veterans Affairs, military, Department of Defense, or other federally owned practices.

    • ↵b Practices with nonfederal, private/nonclinician, academic, or tribal ownership, those indicating “other” without specifying an ownership type, and practices responding no to every ownership type.

    • ↵c Determined using rural-urban commuting area codes.

    • d State Innovation Models Initiative, Comprehensive Primary Care Initiative, Transforming Clinical Practice Initiative, community health worker training program, Blue Cross Blue Shield Patient-Centered Medical Home program, and Million Hearts.

    • e New EHR, new billing system, moved locations, staff turnover, and purchased by or affiliated with larger organization.

    • View popup
    Table 2

    Components of the Change Process Capability Questionnaire Strategies Scale (N = 1,181 practices)

    The practice has used the following strategies to improve cardiovascular preventive careAgree or Strongly Agree No. (%)
    Changing or creating systems in the practice that make it easier to provide high-quality care935 (79.2)
    Providing information and skills training891 (75.4)
    Removal or reduction of barriers to better quality of care880 (74.5)
    Periodic measurement of care quality for assessing compliance with any new approach to care816 (69.1)
    Using teams focused on accomplishing the change process for improved care808 (68.4)
    Deliberately designing care improvements to make the care process more beneficial to the patient799 (67.7)
    Using opinion leaders, role modeling, or other vehicles to encourage support for changes757 (64.1)
    Providing to those who are charged with implementing improved care the power to authorize and make the desired changes753 (63.8)
    Reporting measurements of practice performance on CVD prevention measures for comparison with their peers740 (62.7)
    Setting goals and benchmarking rates of performance quality on CVD prevention measures at least yearly683 (57.8)
    Customizing the implementation of CVD prevention care changes to the practice632 (53.5)
    Deliberately designing care improvements so as to make clinician participation less work than before623 (52.8)
    Delegating to nonclinician staff the responsibility to carry out aspects of care that are normally the responsibility of physicians548 (46.4)
    Using rapid cycling, piloting, pretesting, or other vehicles for reducing the risk of negative results for introducing organization-wide change in care492 (41.7)
    • CVD=cardiovascular disease.

    • View popup
    Table 3

    Adjusted Mean Difference in Change Process Capability Questionnaire Strategies Scores by Practice Characteristics Among 1,181 Small to Medium-Size Primary Care Practices

    CharacteristicMultivariable Final Model R2= 22.4% Adjusted Mean Difference
    Practice characteristics
    Practice ownership (Ref: clinician-owned)
     Hospital/health system−3.32a
     FQHC, RHC, IHS, federalc−1.49
     Other, noned0.62
     Missing0.96
    Locatione [Ref: urban core]
     Large town1.29
     Rural area0.65
     Suburban−2.13
    Medically underserved area classification (Ref: No)
     Yes−1.52
     Missing1.46
    External factors
    Received external incentives in prior
     12 mo (Ref: No)
     Yes0.96
     Missing−1.43
    Participation in other demonstration projectsf (Ref: No)
     Yes1.24
     Missing3.10
    Part of an accountable care organization (Ref: No)
     Yes2.74a
     Missing2.23
    Internal factors
    Major disruption(s) in prior 12 mog (Ref: no disruption)
     1 major disruption−0.22
     >1 major disruption−2.68b
     Missing0.33
    Completely electronic EHR (Ref: No, part paper)
     Yes−3.59b
     Missing−1.54
    Produced quality report(s) in prior 6 mo (Ref: No)
     Yes5.09a
     Missing2.96
    Report CQMs at practice level (Ref: No)
     Yes2.21
     Missing5.09b
    Ability to create CQM reports from EHR (Ref: No ability)
     In-house clinician or other staff2.26b
     Outside service/consultant0.76
     Missing0.18
    Routinely discuss clinical quality data (Ref: Never)
     Infrequently1.87
     Often5.56a
     Not available, solo practice4.40b
     Don’t know3.81b
     Missing4.21b
    Use of at least 1 registry (Ref: No)
     Yes3.74a
     Missing2.22
    Guidelines for CVD prevention or managementh (Ref: Not used or clinican agreement to use)
     Included in EHR prompts or standing orders4.45a
     Missing0.41
    • AIC=Akaike Information Criterion; CQM=Clinical Quality Measure; CVD=cardiovascular disease; EHR = electronic health record; FQHC = federally qualified health center, IHS = Indian health services clinics; Ref = reference; RHC = rural health clinic; VA = Veterans Affairs.

    • Note: Final multivariable model was selected using backward model selection by the AIC. The model with the lowest AIC was preferred regardless of statistical significance for individual covariates.

    • ↵a P value <.001.

    • ↵b P value <.05.

    • ↵c Includes FQHCs, RHCs, IHS, and VA, military, Department of Defense or other federally owned practices.

    • ↵d Includes practices with nonfederal, private/nonclinician, academic, or tribal ownership, those indicating “other” without specifying an ownership type, and practices responding “no” to every ownership type.

    • ↵e Location categories determined using rural-urban commuting area (RUCA) codes.

    • ↵f Other demonstrations programs include State Innovation Models initiative, Comprehensive Primary Care Initiative, Transforming Clinical Practice Initiative, community health worker training program, Blue Cross Blue Shield Patient-Centered Medical Home program, and Million Hearts.

    • ↵g Major disruptions include new EHR, new billing system, moved locations, staff turnover, and purchased/affiliated with larger organization.

    • ↵h Guidelines for CVD prevention and management were combined to avoid multicollinearity. A practice was categorized as “Included in EHR prompts or standing orders” if they denoted that in either CVD prevention or CVD management or both.

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The Annals of Family Medicine: 16 (Suppl 1)
The Annals of Family Medicine: 16 (Suppl 1)
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April 2018
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Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices
Bijal A. Balasubramanian, Miguel Marino, Deborah J. Cohen, Rikki L. Ward, Alex Preston, Rachel J. Springer, Stephan R. Lindner, Samuel Edwards, K. John McConnell, Benjamin F. Crabtree, William L. Miller, Kurt C. Stange, Leif I. Solberg
The Annals of Family Medicine Apr 2018, 16 (Suppl 1) S35-S43; DOI: 10.1370/afm.2172

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Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices
Bijal A. Balasubramanian, Miguel Marino, Deborah J. Cohen, Rikki L. Ward, Alex Preston, Rachel J. Springer, Stephan R. Lindner, Samuel Edwards, K. John McConnell, Benjamin F. Crabtree, William L. Miller, Kurt C. Stange, Leif I. Solberg
The Annals of Family Medicine Apr 2018, 16 (Suppl 1) S35-S43; DOI: 10.1370/afm.2172
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