PT  - JOURNAL ARTICLE
AU  - Deborah J. Cohen
AU  - Shannon M. Sweeney
AU  - William L. Miller
AU  - Jennifer D. Hall
AU  - Edward J. Miech
AU  - Rachel J. Springer
AU  - Bijal A. Balasubramanian
AU  - Laura Damschroder
AU  - Miguel Marino
TI  - Improving Smoking and Blood Pressure Outcomes: The Interplay Between Operational Changes and Local Context
AID  - 10.1370/afm.2668
DP  - 2021 May 01
TA  - The Annals of Family Medicine
PG  - 240--248
VI  - 19
IP  - 3
4099  - http://www.annfammed.org/content/19/3/240.short
4100  - http://www.annfammed.org/content/19/3/240.full
SO  - Ann Fam Med2021 May 01; 19
AB  - PURPOSE We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care.METHODS We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW—a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes.RESULTS In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system–owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system–owned practices that implemented these operational changes.CONCLUSIONS There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation.