Primary care medical practices should improve smoking cessation counselling and blood pressure quality metrics in order to make meaningful gains in cardiovascular disease care, reports the American Academy of Family Physicians.
Care improvements specific to their practice size and type should be adopted by medical practices, according to a new study from the national primary care quality improvement initiative EvidenceNOW, just published in The Annals of Family Medicine.
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.
According to American Academy of Family Physicians material published on 11 May 2021, 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 Centres more facilitation was necessary, leading researchers to conclude that "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 prioritisation of operational changes may be critical to successful quality improvement.
The Annals of Family Medicine article – 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.
Author affiliations: Oregon Health & Science University; University of Texas Health School of Public Health; Lehigh Valley Health Network; Regenstrief Institute in the Center for Health Services Research in Indianapolis; and Implementation Pathways at the LLC and VA Center for Clinical Management Research in Michigan
Published in The Annals of Family Medicine in May 2021, 19 (3) 240-248.
Abstract
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, counselling and in the proportion of hypertensive patients with adequately controlled BP.
We analysed 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.
SEE ALSO FROM THE MEDICALBRIEF ARCHIVES
The important role of pharmacists in helping people to quit smoking
Childhood smoking, adult cessation and heart risk — Large Oxford study
American Thoracic Society: New pharmacotherapy guidelines on smoking cessation