title: A group randomized trial of a complexity-based organizational intervention to improve risk factors for diabetes complications in primary care settings: study protocol.
abstract: BACKGROUND
  Most patients with type 2 diabetes have suboptimal control of their glucose, blood pressure (BP), and lipids - three risk factors for diabetes complications. Although the chronic care model (CCM) provides a roadmap for improving these outcomes, developing theoretically sound implementation strategies that will work across diverse primary care settings has been challenging. One explanation for this difficulty may be that most strategies do not account for the complex adaptive system (CAS) characteristics of the primary care setting. A CAS is comprised of individuals who can learn, interconnect, self-organize, and interact with their environment in a way that demonstrates non-linear dynamic behavior. One implementation strategy that may be used to leverage these properties is practice facilitation (PF). PF creates time for learning and reflection by members of the team in each clinic, improves their communication, and promotes an individualized approach to implement a strategy to improve patient outcomes.
  
  
  OBJECTIVE
  The specific objectives of this protocol are to: evaluate the effectiveness and sustainability of PF to improve risk factor control in patients with type 2 diabetes across a variety of primary care settings; assess the implementation of the CCM in response to the intervention; examine the relationship between communication within the practice team and the implementation of the CCM; and determine the cost of the intervention both from the perspective of the organization conducting the PF intervention and from the perspective of the primary care practice.
  
  
  METHODS
  The study will be a group randomized trial conducted in 40 primary care clinics. Data will be collected on all clinics, with 60 patients in each clinic, using a multi-method assessment process at baseline, 12, and 24 months. The intervention, PF, will consist of a series of practice improvement team meetings led by trained facilitators over 12 months. Primary hypotheses will be tested with 12-month outcome data. Sustainability of the intervention will be tested using 24 month data. Insights gained will be included in a delayed intervention conducted in control practices and evaluated in a pre-post design.
  
  
  METHODS
  To test hypotheses, the unit of randomization will be the clinic. The unit of analysis will be the repeated measure of each risk factor for each patient, nested within the clinic. The repeated measure of glycosylated hemoglobin A1c will be the primary outcome, with BP and Low Density Lipoprotein (LDL) cholesterol as secondary outcomes. To study change in risk factor level, a hierarchical or random effect model will be used to account for the nesting of repeated measurement of risk factor within patients and patients within clinics.
authors.affiliation: VERDICT Health Services Research Center, South Texas Veterans Health Care System, San Antonio, TX, USA. parchman@uthscsa.edu
authors.forename: Michael L
authors.initials: ML
authors.lastname: Parchman
authors.forename: Jacqueline A
authors.initials: JA
authors.lastname: Pugh
authors.forename: Steven D
authors.initials: SD
authors.lastname: Culler
authors.forename: Polly H
authors.initials: PH
authors.lastname: Noel
authors.forename: Nedal H
authors.initials: NH
authors.lastname: Arar
authors.forename: Raquel L
authors.initials: RL
authors.lastname: Romero
authors.forename: Raymond F
authors.initials: RF
authors.lastname: Palmer