title: Evaluating an integrated approach to clinical quality improvement: clinical guidelines, quality measurement, and supportive system design.
abstract: BACKGROUND
  Implementing clinical practice guidelines to change patient outcomes presents a challenge. Studies of single interventions focused on changing provider behavior demonstrate modest effects, suggesting that effective guideline implementation requires a multifaceted approach. Traditional biomedical research designs are not well suited to evaluating systems interventions.
  
  
  OBJECTIVE
  RAND and the Army Medical Department collaborated to develop and evaluate a system for implementing guidelines and documenting their effects on patient care.
  
  
  METHODS
  The evaluation design blended quality improvement, case study, and epidemiologic methods. A formative evaluation of implementation process and an outcome evaluation of patient impact were combined.
  
  
  METHODS
  Guidelines were implemented in 3 successive demonstrations targeting low back pain, asthma, and diabetes. This paper reports on the first wave of 4 facilities implementing a low back pain guideline.
  
  
  METHODS
  Organizational climate and culture, motivation, leadership commitment, and resources were assessed. Selected indicators of processes and outcomes of care were compared before, during, and after guideline implementation at the demonstration facilities and at comparison facilities. Logistic regression analysis was used to test for guideline effects on patient care.
  
  
  RESULTS
  Process evaluation documented varied approaches to quality improvement across sites. Outcome evaluation revealed a significant downward trend in the percentage of acute low back pain patients referred to physical therapy or chiropractic care (10.7% to 7.2%) at demonstration sites and no such trend at control sites.
  
  
  CONCLUSIONS
  Preliminary results suggest the power of this design to stimulate improvements in guideline implementation while retaining the power to evaluate rigorously effects on patient care.
authors.affiliation: RAND Health, Santa Monica, California 90407-2138, USA. shan@rand.org
authors.forename: S
authors.initials: S
authors.lastname: Cretin
authors.forename: D O
authors.initials: DO
authors.lastname: Farley
authors.forename: K J
authors.initials: KJ
authors.lastname: Dolter
authors.forename: W
authors.initials: W
authors.lastname: Nicholas
mesh_terms: D000293:Adolescent; D000328:Adult; D001249:Asthma / Q000175:diagnosis / Q000628:therapy; D003920:Diabetes Mellitus / Q000175:diagnosis / Q000628:therapy; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D017116:Low Back Pain / Q000175:diagnosis / Q000628:therapy; D008499:Medical Records; D008875:Middle Aged; D008887:Military Medicine; D017410:Practice Guidelines as Topic; D011786:Quality Control; D011787:Quality of Health Care / Q000592:standards*; D012017:Referral and Consultation; D013997:Time Factors; D017749:Total Quality Management; D014481:United States