Practice-tailored facilitation to improve pediatric preventive care delivery: a randomized trial

Abstract

Objective: Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services.

Methods: In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods.

Results: Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need.

Conclusions: Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.

Trial registration: ClinicalTrials.gov NCT01739166.

Keywords: child; dental caries; lead poisoning; obesity; quality improvement.

FIGURE 1

Flow diagram. ^aMore visits were included for Late-Phase practices because they had 4 months of control time before starting the intervention. FTE, full-time equivalent.

FIGURE 2

Obesity: detection and counseling performed.

FIGURE 3

Lead: appropriate screening performed.

FIGURE 4

Fluoride: varnish applied.

FIGURE 5

Building blocks for reaching high success rates with practice change.

FIGURE 6

A, Practice characteristics by facilitation intensity. B, Practice decision style: by facilitation intensity.