EvidenceNOW: Midwest Cooperative

EvidenceNOW: Advancing Heart Health in Primary Care is an initiative of the Agency for Healthcare Research and Quality (AHRQ) to transform health care delivery by building a critical infrastructure to help smaller primary care practices improve the heart health of their patients by applying the latest medical research and tools. EvidenceNOW established seven regional cooperatives composed of public and private health partnerships that provide a variety of quality improvement services typically not available to small primary care practices. The goal of this initiative is to ensure that primary care practices have the evidence they need to help their patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure control, Cholesterol management, and Smoking cessation. The initiative also includes an independent national evaluation designed to determine if and how quality improvement support can accelerate the dissemination and implementation of new evidence in primary care.

Cooperative Name: Healthy Hearts in the Heartland

Principal Investigator: Abel N. Kho, M.D., M.S., Northwestern University

Cooperative Partners:
Northwestern University [(Chicago Regional Extension Service (REC)]
Alliance of Chicago Community Health Services
American Medical Association
Illinois Department of Public Health
MetaStar, Inc. (Wisconsin REC)
Telligen, Inc. (Illinois Quality Improvement Organization [QIO])
Northern Illinois University (Illinois REC)
Northwestern Memorial Physicians Group
Purdue University (Indiana REC)
University of Chicago

Geographic Area: Illinois, Wisconsin, Indiana

Project Period: 2015–2018

Region and Population

The Midwest Cooperative region encompasses southeastern Wisconsin, northeastern Illinois (including Chicago) and northern Indiana, home to more than 16 million people. Based on US 2010 Census data, this highly diverse population (racially, ethnically and socioeconomically) faces many cardiac health challenges: 31.2 percent have high blood pressure, 29.3 percent are considered obese, 38.1 percent have high cholesterol levels, and 20.5 percent are current smokers.¹ At the same time, 34 percent of these patients live in areas designated by the Health Resources and Service Administration (HRSA) as Medically Underserved or are part of Medically Underserved Populations and may have less access to primary care.²

Specific Aims

1. Evaluate the ability of small practices in the region to (a) implement point-of-care and population management quality improvement strategies to improve the ABCS of cardiovascular disease prevention, and (b) implement performance measurement software to evaluate performance on the ABCS and allow regional benchmarking.
2. Conduct a practice-randomized trial to determine whether point-of-care strategies improve ABCS performance measures compared to baseline, and whether adding locally tailored population management strategies to point-of-care strategies improves performance on the ABCS measures more than point-of-care strategies alone.
3. Deploy an open-source quality measurement platform (popHealth) to establish a regional quality improvement benchmark based on participating practice ABCS measures and to enable longitudinal tracking of electronic clinical quality measures across the region.

Reach

• Number of Participating Practices: 216
• Practice characteristics
  • Location
    • 89.9 percent urban
    • 6.7 percent rural
    • 3.0 percent suburban
    • 0.5 percent other
  • Number of Clinicians
    • 29.2 percent solo
    • 45.3 percent 2-5 clinicians
    • 15.4 percent 6-10 clinicians
    • 10.1 percent 11 or more clinicians
  • Ownership
    • 37.6 percent clinician owned
    • 26.0 percent hospital or health system-owned
    • 27.0 percent FQHC
    • 2.0 percent Other/Multiple
    • 7.4 percent unknown

Note: These preliminary data are provided for illustrative purposes. Numbers are subject to change based on final data analyses. Data courtesy of ESCALATES, the EvidenceNOW independent national evaluator under AHRQ grant number R01HS023940-01. For more information about the national evaluation, visit: www.escalates.org

Updates on Key Project Components

Support Strategy

The Midwest Cooperative helps practices improve the quality of care and adoption of the ABCS through individual point-of-care and population management strategies:

• Point-of-care strategies that focus on improving the quality and efficiency of care delivered to individual patients during office visits. These strategies will include educational tools and electronic reminders to enhance aspirin prescription and cholesterol management; education and patient self-management tools to improve blood pressure control; and staff training and electronic reminders to encourage use of the "5As" (Ask, Advise, Assess, Assist, Arrange) for smoking cessation.
• Population management strategies that use systems-based approaches to improve population health. These strategies will include creating lists of patients eligible for aspirin or cholesterol interventions so that practices can conduct direct outreach, developing partnerships with community pharmacists to enhance team-based blood pressure care, and connecting documented smokers to local quit lines and other telephone-based smoking cessation counseling.
• Learning Collaborative. The Learning Collaborative will offer multiple opportunities for practice facilitators to engage in shared learning:
  • Regular training webinars and meetings
  • Access to national and regional quality improvement experts
  • A listserv for information-sharing and problem-solving
• Practice will benefit from
  • Monthly site visits by practice facilitators or other content experts
  • Access to quality improvement tools and resources

Update:

The Midwest Cooperative enrolled 226 practices in four waves, and 216 are still active in the program. Some observations about progress include:

• Practice facilitators from six organizations are actively engaging with practices from February 2016 through October 2017.
• Each cohort (wave) spans a 12-month intervention followed by a 6-month maintenance period, with data collected at the baseline, 12- and 18-month points.
• 160 practices have been connected to the popHealth integrated population health reporting tool (across seven EHRs).
• Practice facilitators distributed a curated inventory of relevant community resources (generated by the software package HealtheRx) to help practices connect patients to needed services.

Evaluation

The Midwest Cooperative is using a two-arm, cluster randomized comparative effectiveness trial. In this design, care sites are enrolled and then randomly assigned to the intervention in cohorts, with all sites receiving an intervention. Practices were assigned either to point-of-care strategies alone or point of care plus population management strategies.

Update

The Midwest Cooperative is collecting electronic clinical quality measures (eCQMs), practice- and individual-level staff/provider surveys, implementation and exposure information, and qualitative data to create a complete picture of the impact of practice facilitation on preventive cardiology in small practices. It also is identifying practical and technological obstacles that need to be addressed to maximize the beneficial effect of these practice facilitation techniques.

Strategies for Disseminating Study Findings and Lessons Learned

Update:

• The cooperative plans to disseminate study findings via brand-focused materials distributed through partner networks, a Web site, social media outlets, and scientific publications and presentations.

Comment From Principal Investigator

Abel Kho, M.D., M.S.

"Our cooperative focuses on using innovative data analysis strategies to improve quality of care. Practice facilitators help small clinics use their own data to gain a clear picture of the care provided and identify ways they can improve quality and cardiovascular health outcomes."

Publications and Other Dissemination Activities

The Midwest Cooperative has made presentations at several national conferences as well as produced webinars on strategies for improving patient care and reporting quality data.

Presentations:

• Collective Efforts to Overcome Quality Measurement Challenges: Lessons from a Primary Care Learning Community [AcademyHealth, 2017]
• Use of the popHealth Open-Source Quality Measure Engine to Support Cardiovascular Care at Small- and Medium-Sized Practices [AMIA, 2017]
• Leveraging popHealth^® and an active open source community to improve heart health in small- to medium-sized practices [OSEHRA Open Source Summit, 2016]
• Using Electronic Clinical Quality Measures Data to Improve Primary Care Practice: Early Learning from AHRQ's EvidenceNOW Initiative [STFM Conference on Practice Improvement, 2017]

Webinars:

• An Overview of the CMS Quality Payment Program (QPP) Webinar [2017]
• Crash Course: Diving Deep into MIPS [2017]
• Implementing a Practice-Led Self-Measured Blood Pressure Monitoring Program [2017]
• Improving Health Outcomes: Blood Pressure Measurement [2017]
• Improving Health Outcomes: Reducing Clinical Inertia for Controlling Hypertension [2017]
• Partnering with Pharmacists to Optimize Patient Care [2017]
• Patient Engagement and Education Outside of the Office [2017]
• Smoking Cessation Strategies that Work Webinar [2017]
• Using EHR Data and Other Methods to Improve Care: Lessons Learned [2017]
• An Overview of the CMS Quality Payment Program (QPP) Webinar [2017]
• Progress and Challenges in the Care of Women with Cardiovascular Disease [2017]
• Patient Engagement: Types, Trends, and Opportunities [2017]
• Nuts and Bolts: Pulling and Analyzing EHR Reports to Improve Care [2016]
• Treating Your Patients for Tobacco Dependence [2016]
• Understanding the New Cholesterol Performance Measure [2016]
• Harnessing Community Resources to Improve Patient Care [2016]

References

1. Centers for Disease Control and Prevention. SMART: Behavioral Risk Factor Surveillance System City and County Data. 2013. http://apps.nccd.cdc.gov/BRFSS-SMART/index.asp. Accessed May 27, 2016.
2. Health Resources and Services Administration. Shortage Designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations. http://www.hrsa.gov/shortage. Accessed May 27, 2016.