Article Figures & Data
Tables
Characteristic Practices in Smoking Analysis (N = 59) Practices in BP Analysis (N = 73) Practice characteristics Ownership, No. (%) Clinicians 36 (61.0) 43 (58.9) Hospital/health system 13 (22.0) 16 (21.9) FQHC 7 (11.9) 9 (12.3) RHC/IHS 3 (5.1) 5 (6.8) Practice size, No. (%) Solo practice 19 (32.2) 21 (28.8) 2-5 clinicians 31 (52.5) 41 (56.2) 6-10 clinicians 6 (10.2) 8 (11.0) ≥11 clinicians 2 (3.4) 2 (2.7) Missing 1 (1.7) 1 (1.4) Geographic region/Cooperative, No. (%) Midwest (IN, IL, WI) 12 (20.3) 15 (20.5) North Carolina 8 (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) Oklahoma 7 (11.9) 9 (12.3) Southwest (CO, NM) 9 (15.3) 11 (15.1) Virginia 4 (6.8) 8 (11.0) Location, No. (%) Rural area 4 (6.8) 8 (11.0) Large town 10 (16.9) 12 (16.4) Suburban 4 (6.8) 6 (8.2) Urban core 41 (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.
Pathway Consistency, % (No./N) Raw Coverage, % (No./N) Unique Coverage, % (No./N) Cases Included in Pathwaya Process improvement = 1
AND
Ownership = clinician93 (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 hours91 (10/11) 34 (10/29) 21 (6/29) A3, A4, B1, B2, B3, B5, B7, B12, G1, G3 Identify referral resources = 1
AND100 (6/6) 20 (6/29) 10 (3/29) A5, C2, E1, E2, F1, G4 Referral tracking = 0
ANDDuration of facilitation = 10-24.9 hours Overall model 92 (22/24) 76 (22/29) N/A - Table 3.
Qualitative Excerpts Demonstrating Pathways Linked to a ≥10-Point Gain in Smoking Outcome
Pathway Excerpt 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 ownershipBasically, 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: 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
Documentation: reported working to change documentation behavior after someone in practice learned they were not documenting correctly
Identify referral resources: gave information about quitlines and other resources to patients
AND
25-49.9 facilitation hoursTheir 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 facilitationWith 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.
Pathway Consistency, % (No./N) Raw Coverage, % (No./N) Unique Coverage, % (No./N) Cases Included in Pathwaya Take second BP = 1
AND
Documentation = 1
AND
Ownership = clinician91 (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 hours100 (3/3) 12 (3/26) 4 (2/26) A1, B8, B9 Measurement training = 2
AND
Duration of facilitation = 10-24.9 hours75 (3/4) 12 (3/26) 4 (2/26) E2, G4, G5 Measurement training = 1 (ie, without follow-up)
AND
Size = solo clinician73 (8/11) 31 (8/26) 15 (4/26) A2, A3, A6, A7, B8, F1, F4, F5 Overall model 82 (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
Pathway Excerpt Measurement training: educated practice staff about how to take an accurate BP
AND
Solo practiceWe 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 ownershipWe’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 hoursWe 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 hoursThey 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
