A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial

Abstract

Background: Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care.

Objective: To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke.

Design: 2-year randomized, controlled clinical trial with the practice as the unit of randomization.

Setting: 20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record.

Participants: 44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients.

Interventions: All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches.

Measurements: The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator.

Results: Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]).

Limitations: The study involved a small number of practices and lacked a pure control group.

Conclusions: Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.