A randomized trial of practice-based education to improve delivery systems for anticipatory guidance

Abstract

Background: Communication between physicians and patients is an important component of medical encounters and has been identified by the Institute of Medicine as a point of intervention to increase quality of care. In pediatric health maintenance visits, substantial recommended communication, in the form of anticipatory guidance, is not provided.

Objective: To examine the effectiveness of an intervention of continuing medical education and process improvement methods to implement "office systems" to improve the delivery of anticipatory guidance for parents of young children.

Methods: We performed a randomized controlled trial of a practice-based quality improvement intervention among 44 pediatric practices in North Carolina. In the 22 intervention practices, project staff coached practice staff in auditing performance and identifying, testing, and implementing new care processes to improve delivery of anticipatory guidance. We surveyed parents of 1-month-olds and 6-month-olds regarding their recollection of anticipatory guidance as well as parent knowledge and parent behaviors and used cluster analysis to determine the effects of the intervention.

Results: The proportion of parents of 1-month-olds who reported that they received all age-appropriate anticipatory guidance changed from 15.9% (95% confidence interval [CI], 8.9%-26.7%) to 10.0% (95% CI, 5.1%-18.8%) in the control practices and from 7.3% (4.1%-12.9%) to 24.0% (95% CI, 14.6%-36.9%) in the intervention practices (difference between 2 differences, P = .002). The proportion of parents of 6-month-olds who reported that they received all age-appropriate anticipatory guidance changed from 8.2% (95% CI, 3.6%-17.8%) to 5.4% (95% CI, 2.8%-10.2%) in the control practices and from 2.2% (95% CI, 0.8%-5.9%) to 18.1% (95% CI, 10.3%-29.9%) in the intervention practices (difference between 2 differences, P = .001). There were no differences in self-reported parent knowledge and parent behavior.

Conclusion: An office system intervention improved parent reports of quantity of anticipatory guidance but did not change parent knowledge or parent behavior. Future research should examine how to use systems improvement methods to improve the impact of anticipatory guidance.