The American Academy of Family Physicians defines quality improvement (QI) as "a systematic, formal approach to the analysis of practice performance and efforts to improve performance."8 Primary care practices with a strong QI orientation seek to continuously improve their own processes of care and improve patient health outcomes.9 Practices engaged in QI identify areas of their performance in need of improvement, set goals for the clinical and practice performance outcomes they aim to achieve, and identify the appropriate methods or approaches to achieve those goals.
Implementing primary care quality improvement on a national scale requires effectively disseminating the latest evidence to practices. It also requires that practices have the capacity and skills to engage in QI activities based on that evidence. AHRQ funds patient-centered outcomes research to generate new evidence for primary care, as well as dissemination and implementation (D&I) research on how evidence-based practices are translated and used in clinical settings.10 AHRQ also works to disseminate evidence to practices and clinical teams, and develops QI implementation tools and resources to help practices implement evidence-based practices to improve the care of their patients.
Below we include a summary of AHRQ's grants, contracts, and resources that focus on practice and quality improvement in primary care.
Grants with a focus on health equity are indicated with this icon.
Grants
Thirty-three AHRQ primary care grants actively funded during FYs 2021 and 2022 were mainly focused on practice and quality improvement. This included 12 R18s (Research Demonstration and Dissemination Projects), 9 U18s (Research Demonstration/Cooperative Agreements), 5 R01s (Research Projects), 3 R13s (Support for Conferences and Scientific Meetings), 2 R03s (Small Research Project Grants), 1 K01 (Research Career Program), and 1 K08 (Mentored Clinical Scientist Development Award). Another 22 grants included some focus on the topic of practice and quality improvement and are described in other sections of this report, including Person-Centered Care (10), Digital Healthcare (9), Healthcare Systems and Infrastructure (1), Health Equity (1), and Primary Care Workforce (1).
Below are tables, organized by subtopic, which include short summaries of each of the 33 primary care grants focused mainly on practice and quality improvement. The seven subtopics include improving care and prevention for cardiovascular disease or diabetes, improving the quality of care for other specific health conditions, electronic health record (EHR)-based tools to improve care for sexual and reproductive health, practice improvements to improve patient safety, impact of care teams on quality of care, conference grants, and grants from the EvidenceNOW initiative.
Improving Care and Prevention for Cardiovascular Disease or Diabetes
Four studies examine efforts to improve evidence-based care for cardiovascular disease or diabetes management and prevention.
| Assessing the Use of Practice Facilitation to Optimize Scale Up of CDS for Hypertension Management (R18) |
|---|
PIs: Hang Pham-Singer; Saul B. Blecker Organization: Fund for Public Health in New York, Inc. Examines if receiving practice facilitation would improve the use of a hypertension focused clinical decision support to effectively improve blood pressure control rates in small primary care practices. (See more information about practice facilitation, including resources in Initiatives and Resources below). |
| Improving Recognition and Management of Hypertension in Youth: Comparing Approaches for Extending Effective CDS for Use in a Large Rural Health System (R18) |
|---|
PIs: Elyse Olshen Kharbanda; Catherine Pastorius Benziger Organization: HealthPartners Institute Compares high and low intensity interventions to implement an EHR-linked clinical decision support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure management in youth. |
|
|---|
PI: Edmond Ramly Organization: University of Wisconsin—Madison; School of Medicine, Family Medicine Aims to develop a customizable toolkit for implementing cardiovascular disease guidelines in primary care after telehealth expansion. The toolkit includes a menu of options to help practices address specific local barriers without requiring the engagement of an expert for a costly tailoring process. |
| Prevent Diabetes Mellitus (PreDM) Clinical Decision Support Intervention in Community Health Centers (R18) |
|---|
PI: Matthew James O'Brien Organization: Northwestern University at Chicago; School of Medicine, Internal Medicine Evaluates a clinical decision support-based intervention to improve care at community health centers for patients with prediabetes. |
Improving the Quality of Care for Other Specific Health Conditions
Three grants examine improving the quality of care for other health conditions.
| Reframing Optimal Management of Pain and Opioids in Older Adults (R18) |
|---|
PIs: Daniel William Berland; Christine Elizabeth Stanik Organization: University of Michigan at Ann Arbor; School of Medicine, Internal Medicine Implements practice improvements for safely prescribing opioids or alternative medications for pain management in older adults in primary care. The project takes a multi-faceted approach, including educating and supporting prescribers, academic detailing, and use of electronic health record technology. |
| Enhanced Kidney Follow-up for AKI Survivors in Care Transitions (the ACT Study) (R03) |
|---|
PI: Erin Frazee Barreto Organization: Mayo Clinic Rochester This pilot feasibility trail evaluates a program that supports patients discharged from the hospital to home after an episode of acute kidney injury. The findings from this study can assist primary care clinicians with providing high-quality, well-coordinated, and patient-centered care for survivors of AKI. |
| Improving Evidence-based Care for Cancer Patients (R01) |
|---|
PI: Graham W. Warren Organization: Medical University of South Carolina; School of Medicine, Radiation-Diagnostic /Oncology Evaluates the use of an "opt-out" (rather than “opt-in”) strategy for increasing enrollment of cancer patients who smoke into an evidence-based smoking cessation program. While this project is not focused on primary care, the findings can help advise how primary care practices can effectively enroll patients in evidence-based smoking cessation programs. |
EHR-Based Tools To Improve Care for Sexual and Reproductive Health
Three studies look at EHR-based tools to improve care for sexual and reproductive health. More studies focused on EHR-based tools, including clinical decision supports, are included in the Digital Healthcare section.
| EHR-based Screening and Intervention for Intimate Partner Violence (R18) |
|---|
PIs: Leslie A. Lenert; Alyssa Ann Rheingold Organization: Medical University of South Carolina; School of Medicine, Public Health & Preventive Medicine Evaluates the implementation of an EHR-based decision support program to support universal screening of women for intimate partner violence (IPV) in primary care clinics. The decision support program includes a referral to a national IPV counseling hotline for those who screen positive. |
| Implementation of Electronic Health Screening in Primary Care to Improve STI Testing (R18) |
|---|
PI: Fahd Aqeeb Ahmad Organization: Washington University; School of Medicine; Pediatrics Integrates an electronic risk assessment tool into four pediatric primary care clinics to help identify adolescents at-risk for sexually transmitted infections during annual preventive maintenance visits. |
| The Community Health Center—Reproductive Life Plan (CHC-RLP) Project (R03) |
|---|
PI: Lisa Marie Masinter Organization: Alliance Chicago Aims to use structured reproductive health assessments, known as reproductive life plans, embedded in the EHR to improve reproductive health care for women in a primary care setting. |
Practice Improvements To Improve Patient Safety
Three grants focus on practice improvement efforts to improve patient safety. More about AHRQ research and initiatives related to patient safety in primary care can be found in the Patient Safety section of this report.
| Implementing Telemedicine to Improve Appropriate Antibiotic Prescribing for Acute Respiratory Tract Infections (R01) |
|---|
PIs: Tamar Barlam; Mari-Lynn Drainoni Organization: Boston Medical Center Examines if telehealth visits can be used to improve the management of acute respiratory tract infections, including reducing inappropriate prescribing of antibiotics in ambulatory care settings. |
| Medical Reversals: De-Implementing Ineffective and Unsafe Treatments (R01) |
|---|
PI: Pinar Karaca-Mandic Organization: University of Minnesota; School of Public Health, Public Health & Preventive Medicine Looks at the de-implementation of treatments that have been found to be ineffective or unsafe. The research team examines the differences in de-implementation across different physicians and health care delivery organizations, taking into account varying characteristics and market environments. While this project is not focused exclusively on primary care, the findings can be used to understand barriers and facilitators to de-implementing the use of ineffective and unsafe treatments and screenings in a primary care setting. |
| ExPERTS-PC: Engaging Patients in Event ReporTing for Safety in Primary Care (K08) |
|---|
PI: Anjana Estelle Sharma Organization: University of California, San Francisco; School of Medicine, Family Medicine Develops a tool for patients to report adverse drug events (ADEs) to their ambulatory care teams. The research team will use natural language processing to identify the patient, caregiver, and healthcare team related causes of ADEs from the reports of a multistate Patient Safety Organization. Using the information about identified causes, the team will develop a prototype of a patient-initiated ADE reporting system using text messaging, and will conduct feasibility testing with patients, family members, and primary care clinic staff. Learn more about this study in a recent NCEPCR webinar: Innovative Use of Technology for Primary Care Delivery. |
Impact of Care Teams on Quality of Care
Two grants study the impact of care teams on the quality of care.
| Impact of Team Configuration and Team Stability on Primary Care Quality (R01) |
|---|
PI: Sylvia J. Hysong Organization: Baylor College; School of Medicine, Internal Medicine Uses Veterans Health Administration data to conduct network analysis to understand the impact of team configurations on quality in primary care. The study aims to develop guidance on the best configurations of primary care teams for delivering high-quality and patient-centered care. |
| Primary Care Physician-Staf f Dyads (“Teamlets”): A Simple, Efficient Means to Improve Healthcare Quality and Decrease Cost? (R01) |
|---|
PI: Lawrence Peter Casalino Organization: Weill Medical College of Cornell University; School of Medicine Looks at the use of “teamlets” in primary care. Teamlets are dyads that include a physician and another staff person who consistently work together to provide care. This study looks at the prevalence of teamlets in primary care, examines the relationship between teamlets and quality, and identifies the characteristics of high-performing teamlets. |
Conference Grants
There are three conference grants on this topic area of Practice and Quality Improvement, described below. More information about practice-based research networks and practice facilitation (the foci of two of the conference grants) is included in Initiatives and Resources.
| Advancing & Improving Measurement and Value in Primary Care (The AIM-PC Starfield Summit) (R13) |
|---|
PI: Beth A Bortz Organization: Virginia Center for Health Innovation The 5th Starfield Summit aims to bring together a diverse group of leaders in primary care research and policy to address the challenge of measurement in primary care with a focused discussion on increasing the value of primary care through measurement and reducing low value care. |
| National Practice-Based Research Network Conferences 2020 to 2022 (R13) |
|---|
PI: Donald E Nease Organization: North American Primary Care Research Group (NAPCRG) This annual conference brings together practice-based research network (PBRN) researchers to share their research strategies, methods, innovations, and results to advance the science of primary care research and improve the quality of primary care. |
| International Conference on Practice Facilitation 2020, 2021, 2022 (R13) |
|---|
PI: Zsolt J Nagykaldi Organization: North American Primary Care Research Group (NAPCRG) This conference serves as a learning community for primary care practice facilitators and works to establish a professional society for professionals working in this field. |
EvidenceNOW Grants
Among the 33 grants in the Practice and Quality Improvement section, there were 15 grants and cooperative agreements from across the three active EvidenceNOW initiatives: EvidenceNOW: Building State Capacity, EvidenceNOW: Managing Unhealthy Alcohol Use, and EvidenceNOW: Managing Urinary Incontinence. For additional information about these initiatives overall and the EvidenceNOW model, please see Initiatives and Resources.
EvidenceNOW: Building State Capacity
|
|---|
PI: Andrea L Cherrington Organization: University of Alabama at Birmingham; School of Medicine, Internal Medicine This grant funds the Alabama Cardiovascular Cooperative to coordinate statewide efforts to improve cardiovascular risk and reduce disparities. Additionally implements a heart health improvement project in 60 primary care clinics throughout Alabama to improve rates of blood pressure control and screening for smoking status. |
|
|---|
PIs: James E Bailey; Benjamin S Heavrin Organization: University of Tennessee Health Science Center; School of Medicine, Internal Medicine This grant funds the Tennessee Heart Health Network (THHN), which will leverage existing infrastructure to identify and implement evidence-based interventions to improve quality of care for cardiovascular disease in primary care across the State. The THHN will specifically target hypertension control and smoking cessation to help reduce disparities in cardiovascular outcomes. |
|
|---|
PIs: Shari Danielle Bolen; Aleece Caron Organization: Case Western Reserve University; School of Medicine; Internal Medicine Expands a nascent statewide cardiovascular health collaborative in Ohio and establishes a sustainable external quality improvement (QI) support infrastructure in the State. The project will also implement and evaluate a QI intervention for heart health that will be co-designed with primary care practices. |
|
|---|
PIs: Anya Day; Theresa L Walunas Organization: Altarum Institute The Healthy Hearts for Michigan (HH4M) project establishes a statewide cooperative in MI to provide QI support to help primary care practices implement interventions to improve hypertension management and tobacco cessation. These efforts will be coupled with optimization of health information technology and telehealth approaches to address barriers to access in rural parts of the State. |
EvidenceNOW: Managing Unhealthy Alcohol Use
|
|---|
PI: Alexander H Krist Organization: Virginia Commonwealth University; School of Medicine, Family Medicine Brings together 125 primary care practices in 5 regions throughout Virginia to participate in an intervention to implement evidence-based screening, counseling, and treatment for unhealthy alcohol. Practice support includes practice facilitation, education and training, shared learning and best practices, screening and counseling toolkits, data support, and assessment with feedback. |
| Intervention in Small Primary Care Practices to Implement Reduction in Unhealthy Alcohol usE (INSPIRE) (R18) |
|---|
PIs: Abel N Kho; Theresa L Walunas Organization: Northwestern University at Chicago; School of Medicine, Internal Medicine Tests the feasibility and effectiveness of office-based screening for unhealthy alcohol use supported by behavioral and medication-based interventions in primary care practices. Practices receive support for implementation through an integrated platform of education, practice facilitation, and embedded EHR technology. |
| Facilitating Alcohol Screening and Treatment (FAST), Colorado (R18) |
|---|
PI: Walter Perry Dickinson Organization: University of Colorado Denver; School of Medicine, Family Medicine Conducts a cluster randomized trial to compare approaches for supporting primary care practices to improve their identification and treatment management of unhealthy alcohol use among adults, including screening, brief intervention, medication assisted therapy, and referral to treatment. The two approaches being compared include an in-person practice facilitation intervention and a virtual practice facilitation intervention. The virtual intervention includes an e-learning module to guide the virtual group sessions. |
| Screening and Management of Unhealthy Alcohol Use in Primary Care: Dissemination and Implementation of PCOR Evidence (R18) |
|---|
PIs: Darren A Dewalt; Daniel E Jonas Organization: University of North Carolina Chapel Hill; School of Medicine, Internal Medicine Aims to determine if primary care practice facilitation can support rapid dissemination and implementation of evidence-based screening, counseling, and medication assisted therapy for unhealthy alcohol use. In addition, the research team aims to test if providing embedded telehealth services accelerates dissemination and implementation for practices with slower uptake. |
| ANTECEDENT (Partnership to Enhance Alcohol Screening, Treatment, and Intervention) (R18) |
|---|
PIs: Melinda Marie Davis; John Muench Organization: Oregon Health & Science University; Medicine Aims to have practice facilitators help 150 primary care practices in Oregon implement screening and brief intervention (SBI), medication assisted treatment (MAT), and referral to treatment as part of routine care to address unhealthy alcohol use. The study will evaluate the impact of foundational and supplemental implementation support on SBI, MAT, and quality improvement capacity in participating primary care clinics. |
| The Michigan Sustained Patient-centered Alcohol-Related Care (MI-SPARC) Trial (R18) |
|---|
PI: Katharine Bradley Organization: Kaiser Foundation Research Institute Brings together the expertise of Kaiser Permanente Washington Health Research Institute (KPWHRI) in implementing evidence-based care for treating unhealthy alcohol use with Altarum Institute’s experience effectively engaging small and medium sized primary care practices throughout Michigan in quality improvement efforts. The project will specifically test if involvement in MI-SPARC increases practice use of screening and brief intervention and medication assisted treatment for alcohol use disorder. |
EvidenceNOW: Managing Urinary Incontinence
|
|---|
PI: Jennifer Tash Anger Organization: University of California, San Diego; School of Medicine, Urology Aims to improve the quality of urinary incontinence care provided to a diverse population of women in primary care, with the goals of improving care and reducing the need for specialty care. Three Southern California medical groups (a total of 60 clinics) will participate in a practice-based incontinence intervention. The intervention will be led by a “clinical champion dyad” including a primary care provider and urologist/ urogynecologist from each medical group and will include physician education and performance feedback, electronic decision support, patient education from dedicated advanced practice providers, and an electronic referral service. |
| Improving Primary Care Understanding of Resources and Screening for Urinary Incontinence to Enhance Treatment (PURSUIT) (U18) |
|---|
PIs: Alayne Denise Markland; Elizabeth Camille Vaughan Organization: University of Alabama at Birmingham; School of Medicine, Internal Medicine Aims to improve access for women Veterans in the southeastern U.S. to evidence-based, nonsurgical treatment for urinary incontinence. Compares the effectiveness of the interactive treatment modality with or without additional urinary incontinence clinical expertise delivered via telehealth in 62 primary care practices that treat women Veterans. Participating practices receive practice facilitation support, training, and health information technology assistance. Researchers explore women Veterans’ and providers’ perceptions of remote urinary incontinence treatment to advise future scalability. |
| Empowering Women and Providers for Improved Care of Urinary Incontinence: EMPOWER Study (U18) |
|---|
PIs: Adonis K Hijaz; Goutham Rao Organization: University Hospitals of Cleveland Uses an integrated, multilevel approach to address key barriers to diagnosing and managing urinary incontinence in primary care. The approach will be implemented across a large network of primary care practices, and include large-scale screening, empowering patients to discuss urinary incontinence with their providers, provider education and training, practice facilitation through nurse navigation, and a “chatbot” to support patient self-management. The project will also implement a system-based strategy for streamlined referrals and treatment. |
| Identify, Teach and Treat (IT2): Automating Clinical Decision Pathways for the Care of Women (U18) |
|---|
PIs: Kimberly Sue Kenton; Steven Persell Organization: Northwestern University at Chicago; Schools of Medicine, Internal Medicine This project’s multi-level implementation strategy aims to improve care for urinary incontinence for women in primary care through systematic and equitable screening, supporting patient-centered decision making for selecting treatment options, and accelerating the uptake of evidence-based nonsurgical treatment modalities. This project will take place in the largest health system in Illinois, with 65 primary care practices and 327 primary care physicians. |
| Bridging Community-based Continence Promotion and Primary Care (U18) |
|---|
PIs: Heidi Wendell Brown; Kathryn E Flynn; Joan Marie Neuner Organization: University of Wisconsin—Madison; School of Medicine Aims to increase the proportion of patients who are screened and offered treatment for urinary incontinence (UI) in 50 primary care practices. The intervention, called UI Assist, includes screening, education, and evidence-based treatment. The research team will also compare implementation of UI Assist alone or in combination with partnership building to help practices overcome barriers to intervention implementation. |
Initiatives and Resources
AHRQ has initiatives as well as resources related to Practice and Quality Improvement in primary care that were ongoing or new in 2021 and 2022. These include AHRQ’s EvidenceNOW initiatives, and materials related to practice facilitation and practice-based research networks (PBRNs). Additional information and links are included below.
AHRQ’s EvidenceNOW model serves as a “blueprint for delivering external support to primary care practices to healthcare quality and implement new evidence into care delivery.”11 The model is defined by the following core services delivered as part of the external support to primary care practices:
- Practice facilitation and coaching
- Health information technology support
- Shared learning collaboratives
- Expert consultation
- Data feedback and benchmarking
EvidenceNOW Tools for Change is a searchable database of tools and resources that primary care practices and those who support practices can use to implement quality improvement, organized based on a key driver diagram. The curated collection of resources included in Tools for Change contains over 100 tools and continues to be developed over time. Newly developed tools from 2021 and 2022 include:
- Integrating Cardiovascular Disease Risk Calculators into Primary Care
- Recruitment and Retention of Primary Care Practices in Quality Improvement Initiatives: A Toolkit
The EvidenceNOW model was developed based on EvidenceNOW: Advancing Heart Health—the first EvidenceNOW initiative which launched in 2015. While the 6 grants for this initiative ended in 2018, AHRQ has continued to develop materials to share what was learned. These recent materials include the following:
- Videos Tell the Story of EvidenceNOW: Advancing Heart Health
- EvidenceNOW: A Model for Heart Health and Beyond
- Bridging Research & Practice in Primary Care: Fact Sheet
Building on the success of EvidenceNOW: Advancing Heart Health, AHRQ has gone on to fund three additional initiatives based on use of the EvidenceNOW model to provide external support to implement evidence into primary care. These three initiatives are described below:
- EvidenceNOW: Building State Capacity. The aim of this initiative is to build state capacity and infrastructure to support Primary care practices with implementing evidence-based heart health interventions, and decrease health disparities, in States with a high prevalence of preventable cardiovascular events. This initiative includes four grantees in Alabama, Ohio, Michigan, and Tennessee (described in greater detail in the grants section above), and a technical assistance and evaluation contract (led by Abt Global).12
- EvidenceNOW: Managing Unhealthy Alcohol Use. This initiative aims to increase the implementation of screening for unhealthy alcohol use in primary care, followed by a brief intervention and referral to treatment as indicated.13 AHRQ funded six grants in Michigan, Virginia, North Carolina, Colorado, Oregon, and Illinois and Wisconsin (described in greater detail in the grants section above), as well as a Resource Center and Evaluation contract led by NORC at the University of Chicago.
- EvidenceNOW: Managing Urinary Incontinence. This initiative, launched in 2022, supports primary care practices to implement evidence-based, nonsurgical treatments for urinary incontinence in women, including behavioral approaches, medications, and neuromodulation. The five grantees include University of Alabama at Birmingham; University of Wisconsin, Madison; University of California, San Diego; Northwestern University; and University Hospitals of Cleveland (described in greater detail in the grants section above). AHRQ also funded a contract to support a learning community for the grantees and evaluate the program's impact, led by the RAND Corporation.14 Materials developed for this project in 2021 and 2022 include:
Practice Facilitation
Practice facilitation is an approach to supporting quality improvement in primary care practices with individualized trained practice coaches (known as practice facilitators).15 In addition to previously developed resources to describe practice facilitation, train practice facilitators, and advise program development and deployment, AHRQ developed the following materials in 2021 and 2022:
- AHRQ Practice Facilitation Training Modules. These 20-30 minute interactive modules—based on AHRQ’s Primary Care Practice Facilitation Curriculum—teach practice facilitators the skills they need to be effective. The modules are available to upload to learning management systems to track their completion by trainees by sending an email request to: pftraining@ahrq.hhs.gov.
- Obtaining and Using Data in Practice: A Handbook for Health IT Advisors and Practice Facilitators. This handbook provides detailed guidance for people who support primary care practices with their health information technology (IT) needs related to quality improvement and practice transformation efforts.16
- This infographic provides an overview of the most effective strategies used by practice facilitators based on findings from the EvidenceNOW: Advancing Heart Health initiative.
AHRQ also provides a grant to fund the annual International Conference on Practice Facilitation (ICPF) hosted by the North American Primary Care Research Group (NAPCRG), as described in grants above.
Practice-based Research Networks (PBRNs)
AHRQ defines a PBRN as “a group of ambulatory practices devoted principally to the primary care of patients, and affiliated in their mission to investigate questions related to community- based practice and to improve the quality of primary care.”17 PBRNs serve as a “natural laboratory” for conducting dissemination and implementation (D&I) research in a real-world practice setting.
After previously funding the development of PBRNs and providing support through a national resource center and an electronic research repository, AHRQ’s direct support to PBRNs has decreased in recent years. However, several of the AHRQ funded grants in 2021 and 2022 are conducted by or with PBRNS. In addition, AHRQ provides a grant to fund the PBRN Conference hosted by NAPCRG, as described in grants above. In the future, AHRQ plans to reengage and more actively support PBRNs.
