EvidenceNOW: Northwest 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 Northwest: Improving Practice Together

Principal Investigator: Michael L. Parchman, M.D., M.P.H., Kaiser Permanente Washington Health Research Institute

Cooperative Cooperative Partners:
The MacColl Center for Health Care Innovation Kaiser Permanente Washington Health Research Institute
Oregon Rural Practice-based Research Network (ORPRN) at Oregon Health & Science University
Institute of Translational Health Sciences at University of Washington
Qualis Health

Geographic Area: Washington, Oregon, Idaho

Project Period: 2015–2018

Region and Population

The Pacific Northwest consists of urban centers, rural agricultural communities, Native American reservations, and sparsely populated counties. The region has a growing urban and rural Hispanic population, as well as rapid overall population growth in the urban cores. Heart health indicators vary considerably across the region. They are worse in small rural counties where primary care has fewer resources than in urban areas. Rates of death from heart attack in the small rural counties are higher than larger metropolitan counties. The death rate from stroke is higher in the Pacific Northwest than in other parts of the United States.¹

Specific Aims

1. Identify, recruit, and conduct baseline assessments in 250-320 small- to medium-sized primary care practices across Washington, Oregon, and Idaho during the project’s first year.
2. Provide comprehensive practice support to build quality improvement (QI) capacity within these practices.
3. Disseminate and support the adoption of patient-centered outcomes research (PCOR) findings relevant to aspirin use, blood pressure and cholesterol control, and smoking cessation (ABCS) quality measures.
4. Conduct a rigorous evaluation of strategies that enhance the effectiveness of external practice support to improve QI capacity, implement PCOR findings, and improve ABCS measures.
5. Assess the sustainability of changes made in QI capacity and ABCS improvements and develop a model of scale-up and spread for improving QI capacity in primary care practices.

Reach

• Number of Participating Practices: 209
• Location
  • 45 percent urban
  • 18 percent rural
  • 36 percent suburban
  • 1 percent suburban
• Number of Clinicians
  • 18 percent solo
  • 53 percent 2–5 clinicians
  • 17 percent 6-10 clinicians
  • 12 percent 11 or more clinicians
  • 1 percent unspecified
• Ownership
  • 40 percent clinician owned
  • 39 percent hospital or health system-owned
  • 17 percent FQHC

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

Each participating practice receives 15 months of support from practice facilitators in two key areas:

• Health information technology support and use of data for Physician Quality Reporting System (PQRS) reporting and QI. The Cooperative helps the practices improve PQRS reporting of ABCS measures with a tailored Action Plan. Practices have varying experience with PQRS reporting and need different levels of information technology support. Practice facilitators support practices in person and through ongoing phone and secure Internet communication to help with electronic health record (EHR) data extraction.
• External practice QI support. This support enhances the practices' capacity to use new PCOR findings to change their care practices and improve ABCS measures. To build their QI capacity to adopt and implement PCOR heart health findings, practices will be assessed and then receive tailored external support through practice facilitation (i.e., a kick-off meeting, face-to-face visits, regular phone calls) and shared learning opportunities (i.e., webinars and office hours led by content experts and practice facilitators). Practice facilitators administer the Quality Improvement Change Assessment (QICA), a tool developed by the Cooperative to determine a practice’s need for practice improvement assistance. Facilitators review the tool with the practice team at the initial welcome visit and again around the fourth in-person visit, which will occur around the 12th month.

The study will compare the effectiveness of two enhanced practice support activities in addition to practice facilitation:

• Shared learning opportunities through site visits. Practices randomized to this enhanced practice support activity visited an innovative primary care practice. They observed the practice and interacted with team members from other primary care practices that also attended the site visit.
• Peer-led educational outreach (academic detailing). Practices randomized to the educational outreach intervention learned about team-based implementation of a cardiovascular disease risk calculator. The activity included an online video followed by a one-on-one phone call between a clinical team and a physician academic expert, and a conference call with other practices participating in this activity.

Practices were randomized to one of four intervention arms of the study using a two-by-two factorial design: practice facilitation only, practice facilitation plus shared learning, practice facilitation plus educational outreach, or practice facilitation plus both shared learning and educational outreach.

Update:

Smaller practices struggled to find the time and resources to accept this additional technical assistance and support from the Northwest Cooperative team. Some expressed frustration with their lack of internal resources to accept this support, largely due to limited clinician and staff time, continual competing demands for external reporting, technology upgrades (electronic health record), and other major disruptions such as clinician and staff turnover.

Evaluation

Staff member surveys and practice surveys are administered at three points in time, and ABCS data is collected quarterly over the study period. The Cooperative will assess changes in State context and also study which strategies enhance the improvement of QI capacity and the adoption of PCOR.

Update:

The Quality Improvement Capacity Assessment (QICA) tool has proven to be one of the most valuable components of the evaluation, and the most helpful roadmap for clinics and their practice facilitators to plan for short and long-term activities. It is associated with ABCS clinical quality measures and tracks closely with observed improvements in QI capacity within each clinic.

Comment From Principal Investigator

Michael Parchman, M.D., M.P.H.

"The smaller primary care practices we have had the joy of working with are essential to the delivery of health care in the U.S. but face many challenges. We have observed many practices consumed with just creating and reporting clinical quality measures, leaving them with little bandwidth to actually work on building their internal quality improvement capacity. Healthy Hearts Northwest has, however, provided a 'North Star' for many practices. As one physician told us, Healthy Hearts kept the clinic grounded in a way that nothing else did. The impact was larger than the cardiovascular measures; it changed the culture of the clinic."

• Leveraged existing relationships: Overall, recruitment success is attributed to existing relationships with providers or health care systems. These relationships were of significant help in recruiting practices within the large health systems in Washington and Oregon.
• Outreach to tribal practices: The cooperative successfully recruited several tribal clinics in Washington and Oregon. This was a population they had hoped to engage in EvidenceNOW.
• Alignment with national initiatives: Many practices are preparing for upcoming payment reform, so communicating how EvidenceNOW could help practices become ready to gather and extract quality improvement data was key.

Publications and Other Dissemination Activities

The Northwest Cooperative has published two articles and made presentations at several national conferences.

Publications:

• Engaging Primary Care Practices in Studies of Improvement: Did you budget enough for practice recruitment? [AHRQ Journal Supplement; Annals of Family Medicine; Accepted].
• Parchman ML, Fagnan LJ, Dorr DA, Evans P, Cook AJ, Penfold RB, Hsu C, Cheadle A, Baldwin LM, Tuzzio L. Study protocol for "Healthy Hearts Northwest" a 2 X 2 randomized factorial trial to build quality improvement capacity in primary care. Implement Sci. 2016 Oct 13;11(1):138.

Presentations:

• Collective Efforts to Overcome Quality Measurement Challenges: Lessons from a Primary Care Learning Community [Academy Health, 2017]
• Creation of a High-Leverage Change Package to Achieve EvidenceNOW Quality Improvement Goals [NAPCRG, 2017]
• Large Scale Practice Transformation: The Cost of Practice Recruitment, the Healthy Hearts Northwest Experience [NAPCRG, 2017]
• Using the principles of academic detailing to develop a virtual educational outreach intervention in primary care [NAPCRG, 2017]
• Using Electronic Clinical Quality Measures Data to Improve Primary Care Practice: Early Learning from AHRQ’s EvidenceNOW Initiative [STFM Conference on Practice Improvement, 2017]

Reference

1. Mortality Data, Centers for Disease Control and Prevention. Accessed on October 2, 2017 at https://www.cdc.gov/nchs/nvss/mortality_methods.htm.