Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

• Published in: Annals of family medicine Vol. 12; no. 1; pp. 8 - 16
• Main Authors: Dickinson, W. Perry, MD, Dickinson, L. Miriam, PhD, Nutting, Paul A., MD, MSPH, Emsermann, Caroline B., MS, Tutt, Brandon, MA, Crabtree, Benjamin F., PhD, Fisher, Lawrence, PhD, Harbrecht, Marjie, MD, Gottsman, Allyson, West, David R., PhD
• Format: Journal Article
• Language: English
• Published: United States American Academy of Family Physicians 2014
• Subjects: Aged; Diabetes Mellitus - therapy; Family Practice - methods; Family Practice - organization & administration; Family Practice - standards; Female; Humans; Internal Medicine; Male; Middle Aged; Original Research; Outcome and Process Assessment (Health Care); Patient-Centered Care - methods; Patient-Centered Care - organization & administration; Patient-Centered Care - standards; Primary Health Care - methods; Primary Health Care - organization & administration; Primary Health Care - standards; Quality Improvement; quality improvement; practice facilitation; practice-based research; patient-centered medical home; primary health care; family medicine; diabetes mellitus
• ISSN: 1544-1709; 1544-1717
• DOI: 10.1370/afm.1591

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.