Practice facilitation to improve diabetes care in primary care: a report from the EPIC randomized clinical trial.
OBJECTIVE
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.
Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado.
W Perry
WP
Dickinson
L Miriam
LM
Dickinson
Paul A
PA
Nutting
Caroline B
CB
Emsermann
Brandon
B
Tutt
Benjamin F
BF
Crabtree
Lawrence
L
Fisher
Marjie
M
Harbrecht
Allyson
A
Gottsman
David R
DR
West
D000368:Aged; D003920:Diabetes Mellitus / Q000628:therapy*; D005194:Family Practice / Q000379:methods* / Q000458:organization & administration / Q000592:standards; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D018802:Patient-Centered Care / Q000379:methods / Q000458:organization & administration / Q000592:standards; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration / Q000592:standards; D058996:Quality Improvement
diabetes mellitus; family medicine; patient-centered medical home; practice facilitation; practice-based research; primary health care; quality improvement