title: Implementing asthma guidelines using practice facilitation and local learning collaboratives: a randomized controlled trial.
abstract: OBJECTIVE
  Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined.
  
  
  METHODS
  In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute's Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar's test and multivariate modeling were used to evaluate the impact of the interventions.
  
  
  RESULTS
  Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7-3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5-3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation.
  
  
  CONCLUSIONS
  Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.
authors.affiliation: University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
authors.forename: James W
authors.initials: JW
authors.lastname: Mold
authors.forename: Chester
authors.initials: C
authors.lastname: Fox
authors.forename: Angela
authors.initials: A
authors.lastname: Wisniewski
authors.forename: Paula Darby
authors.initials: PD
authors.lastname: Lipman
authors.forename: Margot R
authors.initials: MR
authors.lastname: Krauss
authors.forename: D Robert
authors.initials: DR
authors.lastname: Harris
authors.forename: Cheryl
authors.initials: C
authors.lastname: Aspy
authors.forename: Rachel A
authors.initials: RA
authors.lastname: Cohen
authors.forename: Kurt
authors.initials: K
authors.lastname: Elward
authors.forename: Paul
authors.initials: P
authors.lastname: Frame
authors.forename: Barbara P
authors.initials: BP
authors.lastname: Yawn
authors.forename: Leif I
authors.initials: LI
authors.lastname: Solberg
authors.forename: René
authors.initials: R
authors.lastname: Gonin
mesh_terms: D000328:Adult; D001249:Asthma / Q000628:therapy*; D002648:Child; D005246:Feedback; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D012720:Severity of Illness Index
keywords: asthma; practice facilitation; practice guidelines as topic; practice-based research network; primary health care; quality improvement