Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context

I am so pleased to see Cohen and colleagues look deeply into the factors that make a difference in practices successfully screening and implementing changes which will affect cardiovascular outcomes. This important article helps us understand how the context of practice and the people in those practices can make measurable and important differences in their patients' lives.

Decades ago I had the pleasure of spending time with a solo physician who had been in practice in Northern California for decades. He was telling me about his recent trip to a conference which discussed health risk appraisal. He came home and put together a card with a list of questions about risk and gave it to his town printer and had the cards printed, gave them to his nurse the next day and asked to start giving the cards to his patients to answer the day after that. He was very proud and looked at me and said with a knowing smile "how long would it take to do that in the University system where you practice?" He knew the answer of course - it would be measured in years.

Cohen and colleagues show how a practice leader, committed to their patients and with a sense of ownership not simply of the practice but of its role in their community can work with a clinical team and inspire them to improve screening - likely not because of economic incentives but because it would increase the health of their community. Quality improvement is about people of course, but the data from this study show that it is where and with whom and how well those people work together and support each other that can make a significant difference.

One take away is that intelligent big health systems can create smaller pracitces and trust them to make changes, if everyone agrees on the goals. Just like the doctor I interviewed many years ago, the practice that sees the fruits of their work will continue to make changes and improve care over time. In his Milroy Lecture in 1974 Hart proposed that community GPs, close to and committed to their patients, as the best place to make change. ( The Marriage of Primary Care and Epidemiology) Cohen and colleagues demonstrate elegantly that that premise is still true.