Research ArticleOriginal Research

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

Deborah J. Cohen, Shannon M. Sweeney, William L. Miller, Jennifer D. Hall, Edward J. Miech, Rachel J. Springer, Bijal A. Balasubramanian, Laura Damschroder and Miguel Marino
The Annals of Family Medicine May 2021, 19 (3) 240-248; DOI: https://doi.org/10.1370/afm.2668

Article Figures & Data

Tables

  • Table 1.

    Primary Care Practice Characteristics

    CharacteristicPractices in Smoking Analysis (N = 59)Practices in BP Analysis (N = 73)
    Practice characteristics
    Ownership, No. (%)
        Clinicians36 (61.0)43 (58.9)
        Hospital/health system13 (22.0)16 (21.9)
        FQHC7 (11.9)9 (12.3)
        RHC/IHS3 (5.1)5 (6.8)
    Practice size, No. (%)
        Solo practice19 (32.2)21 (28.8)
        2-5 clinicians31 (52.5)41 (56.2)
        6-10 clinicians6 (10.2)8 (11.0)
        ≥11 clinicians2 (3.4)2 (2.7)
        Missing1 (1.7)1 (1.4)
    Geographic region/Cooperative, No. (%)
        Midwest (IN, IL, WI)12 (20.3)15 (20.5)
        North Carolina8 (13.6)9 (12.3)
        Northwest (OR, WA, ID)4 (6.8)7 (9.6)
        New York City (5 NY boroughs)15 (25.4)14 (19.2)
        Oklahoma7 (11.9)9 (12.3)
        Southwest (CO, NM)9 (15.3)11 (15.1)
        Virginia4 (6.8)8 (11.0)
    Location, No. (%)
        Rural area4 (6.8)8 (11.0)
        Large town10 (16.9)12 (16.4)
        Suburban4 (6.8)6 (8.2)
        Urban core41 (69.5)47 (64.4)
    Patient characteristics
    White, mean (SD), %61.4 (33.7)60.9 (33.4)
    Medicaid coverage, mean (SD), %20.5 (17.1)19.6 (17.2)
    Performance on CQM metric at baseline, No. (%)
        <50%26 (44.1)20 (27.4)
        50%-60%2 (3.4)16 (21.9)
        60%-70%6 (10.2)19 (26.0)
        70%-80%14 (23.7)15 (20.5)
        80%-90%11 (18.6)3 (4.1)

    • BP = blood pressure; CO = Colorado; CQM = clinical quality measure; FQHC = Federally Qualified Health Center; ID = Idaho; IHS = Indian Health Service; IL = Illinois; IN = Indiana, NM = New Mexico; NY = New York; OR = Oregon; RHC = rural health clinic; WA = Washington; WI = Wisconsin.

    • Note: Practices with >90% performance on the smoking CQM (11 practices) or BP CQM (1 practice) at baseline were excluded from analyses because they could not logically achieve a ≥10-point gain.

  • Table 2.

    Pathways Linked to a ≥10-Point Gain in Smoking Outcome

    PathwayConsistency, % (No./N)Raw Coverage, % (No./N)Unique Coverage, % (No./N)Cases Included in Pathwaya
    Process improvement = 1
    AND
    Ownership = clinician    		93 (13/14)45 (13/29)21 (6/29)A1, B1, B2, B3, B4, C1, E1, E2, F1, F2, F12, G1, G2
    Any operational practice change = 1b
    AND
    Duration of facilitation = 25-49.9 hours    		91 (10/11)34 (10/29)21 (6/29)A3, A4, B1, B2, B3, B5, B7, B12, G1, G3
    Identify referral resources = 1
    AND    		100 (6/6)20 (6/29)10 (3/29)A5, C2, E1, E2, F1, G4
    Referral tracking = 0
    AND
    Duration of facilitation = 10-24.9 hours
    Overall model92 (22/24)76 (22/29)N/A

    • N/A = not applicable.

    • ↵a Bold indicates cases uniquely explained by each pathway. Each letter refers to a different Cooperative and each number to a different practice in that Cooperative.

    • ↵b Any 1 of 3 operational changes (documentation, process improvement, and/or referral to resources).

  • Table 3.

    Qualitative Excerpts Demonstrating Pathways Linked to a ≥10-Point Gain in Smoking Outcome

    PathwayExcerpt
    Process improvement: changed practice workflows including processes to ensure clinicians provided brief counseling, changed workflow to enable MAs to provide brief counseling/referral for patients
    AND
    Clinician ownership    		Basically, they had a standing order for these tobacco users ... that will occur during the visit. There were some aspects of it that the MA can do or the person rooming. They had plenty of literature about tobacco cessation, as well as the state quitlines and different resources that are available, so they would do some of that. Then there was more counseling done within the visit, by the provider. (Facilitator interview; 2-5 clinicians; clinician owned)
    Any of 3 operational changes:

    1. Process improvement: changed practice workflows including processes to ensure clinicians provided brief counseling, changed workflow to enable MAs to provide brief counseling/referral for patients

    2. Documentation: reported working to change documentation behavior after someone in practice learned they were not documenting correctly

    3. Identify referral resources: gave information about quitlines and other resources to patients


    AND
    25-49.9 facilitation hours    		Their smoking [assessment and counseling] was a little bit on the low side, so I made sure I went back to it just to tell them, this is the protocol you need to follow. Make sure every patient is being screened for smoking. If there is a patient that’s smoking, make sure they give all the information that’s needed for them to quit. (Facilitator interview; solo practice; clinician owned; facilitation duration 4 [25-49.9 hours with a facilitator])
    What I focused on was helping them to document properly in [their EHR] because [their EHR] has a very specific way to document smoking cessation counseling. It has to be documented in a particular place. (Facilitator interview; 2-5 clinicians; FQHC; facilitation duration 4 [25-49.9 hours with a facilitator])
    We were given a lot of brochures, and I was able to get a lot of free gums and patches for patients that couldn’t get them before.… We [previously] didn’t even know about [the quitline], that we can refer [patients] for that, and that they can receive free patches and gum. (Practice interview; 2-5 clinicians; clinician owned; facilitation duration 4 [25-49.9 hours with a facilitator])
    Identify referral resources: gave information about quitlines and other resources to patients
    WITHOUT
    Tracking referrals: tracked patient’s referral and followed through on a referral to a quitline or another smoking cessation resource
    AND
    10-24.9 hours of facilitation    		With the smoking, we did a lot of patient education. We pushed that 1-800-QUITNOW smoke line that [our state] has. We had tear-out pages where you post it on the wall and people would just tear off the number; something that no one really notices, so we put some in the bathroom. We made sure that they were in the [examination] rooms. (Facilitator interview; 2-5 clinicians; clinician owned; facilitation duration 3 [10-24.9 hours with a facilitator])

    • EHR = electronic health record; FQHC = Federally Qualified Health Center; MA = medical assistant.

  • Table 4.

    Pathways Linked to a ≥10-Point Gain in BP Outcome

    PathwayConsistency, % (No./N)Raw Coverage, % (No./N)Unique Coverage, % (No./N)Cases Included in Pathwaya
    Take second BP = 1
    AND
    Documentation = 1
    AND
    Ownership = clinician    		91 (10/11)38 (10/26)19 (5/26)A2, A3, A6, B8, C3, C4, E2, E3, F3, G2
    Take second BP = 1
    AND
    Duration of facilitation = ≥50 hours    		100 (3/3)12 (3/26)4 (2/26)A1, B8, B9
    Measurement training = 2
    AND
    Duration of facilitation = 10-24.9 hours    		75 (3/4)12 (3/26)4 (2/26)E2, G4, G5
    Measurement training = 1 (ie, without follow-up)
    AND
    Size = solo clinician    		73 (8/11)31 (8/26)15 (4/26)A2, A3, A6, A7, B8, F1, F4, F5
    Overall model82 (18/22)69 (18/26)N/A

    • BP = blood pressure; N/A = not applicable.

    • ↵a Bold indicates cases uniquely explained by each pathway. Each letter refers to a different Cooperative and each number to a different practice in that Cooperative.

  • Table 5.

    Qualitative Excerpts Demonstrating Pathways Linked to a ≥10-Point Gain in BP Outcome

    PathwayExcerpt
    Measurement training: educated practice staff about how to take an accurate BP
    AND
    Solo practice    		We gave different tips on making sure that [the patient is] keeping both feet on the floor, [their] back is supported, they have an empty bladder, they’re not talking. Different tips like that to try to help patients lower their blood pressure. My biggest thing for all my providers that I recommended is to not talk to the patient while you’re doing it. Because I know most nurses or MAs are still trying to collect information while they’re taking blood pressure. (Facilitator interview; solo practice; clinician owned)
    [I] brought his nurse in, and the 3 of us [the facilitator, nurse, and clinician] went through proper blood pressure measurement. I printed out this PowerPoint that we had. ... We went, step by step, how to take the blood pressure. (Facilitator interview; solo practice; clinician owned)
    Take second BP: took second BP during visit if first was elevated
    AND
    Documentation: practice developed method for documenting second or home BP as a discrete field in EHR
    AND
    Clinician ownership    		We’re on the third floor so some patients say, “Oh, great. I’ll take the stairs.” By the time they get here their blood pressure is high, or else they’re late and they’re frantic, or they’ve been fighting the ice and snow, traffic, whatever. So, we get a high blood pressure reading and the MAs didn’t know to retake it at the end of the visit. ... Also understanding which [blood pressure] to record in our EHR and which is counted. If they take 3 blood pressures during the course of the appointment, which one is the one that’s pulling or counting? We had to do some digging and ask some questions and figure all that out. (Practice interview; 2-5 clinicians; clinician owned)
    Take second BP: took second BP during visit if first was elevated
    AND
    ≥50 facilitation hours    		We did workflow-mapping exercises, which [the practice] really liked. What I appreciated is they really spent time thinking about the workflow, and what worked and what didn’t. Whether the BP should be done again before—for example, before the patient sees the provider. (Facilitator interview; ≥11 clinicians; FQHC; facilitation duration 5 [≥50 hours with a facilitator])
    Measurement training: educated practice staff about how to take an accurate BP
    AND
    10-24.9 facilitation hours    		They weren’t aware of the 5-minute rule, waiting, making sure the patient wasn’t talking, feet on the floor. We did some training, internal training, of how to take a blood pressure properly. That went over well. All of the MAs, all the providers, medical staff, went to the training. (Facilitator interview; 2-5 clinicians; system owned; facilitation duration 3 [10-24.9 hours with a facilitator])

    • BP = blood pressure; EHR = electronic health record; FQHC = Federally Qualified Health Center; MA = medical assistant.

Additional Files

  • The Article in Brief


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


    Deborah J. Cohen, and colleagues

    Background In order to make meaningful gains in cardiovascular disease care, primary care medical practices should adopt a set of care improvements specific to their practice size and type. High blood pressure and smoking are among the biggest risk factors associated with cardiovascular disease. Primary care physicians help patients manage high blood pressure and provide smoking cessation interventions. Researchers collected qualitative data from a subset of participating EvidenceNOW primary care practices to answer the following research question: In the context of an initiative focused on improving cardiovascular disease preventive care, what factors and operational changes were linked to improvements in smoking and blood pressure outcomes?


    What This Study Found Researchers found that there is no one central playbook for all types of practices, but they did identify combinations of practice characteristics, amount of practice facilitation, and operational changes linked with improved cardiovascular disease care. Smaller, solo and clinician-owned practices that changed routine aspects of their process, such as training medical assistants to perform accurate blood pressure readings; allowing staff to take repeated blood pressure measures and note second readings in electronic medical records; and equipping clinicians with the tools to perform smoking screening and cessation referrals, were able to make substantial improvements.

    In addition, working with a practice facilitator helped. Smaller practices that participated in a moderate amount of facilitation were able to make these improvements. However, for larger hospital or health system–owned practices and Federally Qualified Health Centers more facilitation was necessary.


    Implications     

    • Researchers conclude: “making operational changes alone—in certain clinical settings—was insufficient to achieve meaningful improvements.” In practices that are part of larger, more complex systems, external facilitation along with prioritization of operational changes may be critical to successful quality improvement.

  • Supplemental Appendixes, Tables & Figures

    Supplemental Appendixes, Tables, & Figures
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