Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial

Abstract

Purpose: We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

Methods: We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

Results: Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.

Conclusions: Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.

Keywords: diabetes mellitus; family medicine; patient-centered medical home; practice facilitation; practice-based research; primary health care; quality improvement.

Figure 1

CONSORT diagram. CONSORT = Consolidated Standards of Reporting Trials; CQI = continuous quality improvement; RAP = reflective adaptive process; SD = self-directed. Notes: 2 RAP practices and 2 CQI practices had limited or no active participation after baseline. Clinicians surveyed using the Assessment of Clinician Diabetes Management included all physicians, nurse practitioners, and physician assistants. Clinicians and staff surveyed using the Practice Culture Assessment included everyone in any role in the practice.