Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation

Donna R Shelley; Thomas Gepts; Nina Siman; Ann M Nguyen; Charles Cleland; Allison M Cuthel; Erin S Rogers; Olugbenga Ogedegbe; Hang Pham-Singer; Winfred Wu; Carolyn A Berry

doi:10.1016/j.amepre.2019.12.013

Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation

Am J Prev Med. 2020 May;58(5):683-690. doi: 10.1016/j.amepre.2019.12.013. Epub 2020 Feb 14.

Authors

Affiliations

¹ Department of Policy and Public Health Management, College of Global Public Health, New York University, New York, New York. Electronic address: donna.shelley@nyu.edu.
² University of California Berkeley, Department of Sociology, Berkeley, California.
³ Department of Population Health, NYU Langone Health, New York, New York.
⁴ Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, New York.
⁵ New York City Department of Health and Mental Hygiene, New York, New York.

PMID: 32067871
DOI: 10.1016/j.amepre.2019.12.013

Abstract

Introduction: Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention.

Study design: The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019.

Setting/participants: A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves.

Intervention: The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines.

Main outcome measures: The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite).

Results: The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002).

Conclusions: Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context.

Trial registration: This study is registered at www.clinicaltrials.gov NCT02646488.

Publication types

Randomized Controlled Trial
Research Support, U.S. Gov't, P.H.S.

MeSH terms

Aspirin / therapeutic use
Blood Pressure / physiology
Cardiovascular Diseases / prevention & control*
Cholesterol / analysis
Cholesterol / blood
Goals
Guideline Adherence / organization & administration*
Health Behavior*
Heart Disease Risk Factors*
Humans
New York City
Smoking Cessation / statistics & numerical data

Substances

Cholesterol
Aspirin

Associated data

ClinicalTrials.gov/NCT02646488

Grants and funding

R18 HS023922/HS/AHRQ HHS/United States