title: Feasibility and impact of implementing a private care system's diabetes quality improvement intervention in the safety net: a cluster-randomized trial.
abstract: BACKGROUND
  Integrated health care delivery systems devote considerable resources to developing quality improvement (QI) interventions. Clinics serving vulnerable populations rarely have the resources for such development but might benefit greatly from implementing approaches shown to be effective in other settings. Little trial-based research has assessed the feasibility and impact of such cross-setting translation and implementation in community health centers (CHCs). We hypothesized that it would be feasible to implement successful QI interventions from integrated care settings in CHCs and would positively impact the CHCs.
  
  
  METHODS
  We adapted Kaiser Permanente's successful intervention, which targets guideline-based cardioprotective prescribing for patients with diabetes mellitus (DM), through an iterative, stakeholder-driven process. We then conducted a cluster-randomized pragmatic trial in 11 CHCs in a staggered process with six "early" CHCs implementing the intervention one year before five "'late" CHCs. We measured monthly rates of patients with DM currently prescribed angiotensin converting enzyme (ACE)-inhibitors/statins, if clinically indicated. Through segmented regression analysis, we evaluated the intervention's effects in June 2011-May 2013. Participants included ~6500 adult CHC patients with DM who were indicated for statins/ACE-inhibitors per national guidelines.
  
  
  RESULTS
  Implementation of the intervention in the CHCs was feasible, with setting-specific adaptations. One year post-implementation, in the early clinics, there were estimated relative increases in guideline-concordant prescribing of 37.6 % (95 % confidence interval (CI); 29.0-46.2 %) among patients indicated for both ACE-inhibitors and statins and 38.7 % (95 % CI; 23.2-54.2 %) among patients indicated for statins. No such increases were seen in the late (control) clinics in that period.
  
  
  CONCLUSIONS
  To our knowledge, this was the first clinical trial testing the translation and implementation of a successful QI initiative from a private, integrated care setting into CHCs. This proved feasible and had significant impact but required considerable adaptation and implementation support. These results suggest the feasibility of adapting diverse strategies developed in integrated care settings for implementation in under-resourced clinics, with important implications for efficiently improving care quality in such settings. CLINICALTRIALS.gov: NCT02299791 .
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97211, USA. rachel.gold@kpchr.org.|OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA. rachel.gold@kpchr.org.
authors.forename: Rachel
authors.initials: R
authors.lastname: Gold
authors.affiliation: OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA. nelsonc@ochin.org.
authors.forename: Christine
authors.initials: C
authors.lastname: Nelson
authors.affiliation: OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA. cowburns@ochin.org.
authors.forename: Stuart
authors.initials: S
authors.lastname: Cowburn
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97211, USA. arwen.l.bunce@kpchr.org.
authors.forename: Arwen
authors.initials: A
authors.lastname: Bunce
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97211, USA. celine.b.hollombe@kpchr.org.
authors.forename: Celine
authors.initials: C
authors.lastname: Hollombe
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97211, USA. james.v.davis@kpchr.org.
authors.forename: James
authors.initials: J
authors.lastname: Davis
authors.affiliation: Oregon Health Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA. muenchj@ohsu.edu.
authors.forename: John
authors.initials: J
authors.lastname: Muench
authors.affiliation: Virginia Garcia Memorial Health Center, 2935 SW Cedar Hills Blvd., Beaverton, OR, 97005, USA. chill@vghmc.org.
authors.forename: Christian
authors.initials: C
authors.lastname: Hill
authors.affiliation: Multnomah County Public Health Department, 426 SW Stark St, 8th Floor, Portland, OR, 97204, USA. meena.mital@multco.us.
authors.forename: Meena
authors.initials: M
authors.lastname: Mital
authors.affiliation: OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA. puroj@ochin.org.
authors.forename: Jon
authors.initials: J
authors.lastname: Puro
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97211, USA. nancy.perrin@kpchr.org.
authors.forename: Nancy
authors.initials: N
authors.lastname: Perrin
authors.affiliation: Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97211, USA. greg.nichols@kpchr.org.
authors.forename: Greg
authors.initials: G
authors.lastname: Nichols
authors.affiliation: Virginia Garcia Memorial Health Center, 2935 SW Cedar Hills Blvd., Beaverton, OR, 97005, USA. aturner@vgmch.org.
authors.forename: Ann
authors.initials: A
authors.lastname: Turner
authors.affiliation: Virginia Garcia Memorial Health Center, 2935 SW Cedar Hills Blvd., Beaverton, OR, 97005, USA. mmercer@vghmc.org.
authors.forename: MaryBeth
authors.initials: M
authors.lastname: Mercer
authors.affiliation: Multnomah County Public Health Department, 426 SW Stark St, 8th Floor, Portland, OR, 97204, USA. victoria.jaworski@multco.us.
authors.forename: Victoria
authors.initials: V
authors.lastname: Jaworski
authors.affiliation: OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA. choward@ohsu.edu.
authors.forename: Colleen
authors.initials: C
authors.lastname: Howard
authors.affiliation: OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA. eabiles@ohsu.edu.
authors.forename: Emma
authors.initials: E
authors.lastname: Abiles
authors.affiliation: Multnomah County Public Health Department, 426 SW Stark St, 8th Floor, Portland, OR, 97204, USA. shaha@careoregon.org.
authors.forename: Amit
authors.initials: A
authors.lastname: Shah
authors.affiliation: Kaiser Permanente Community Benefit, 6880 Paseo Laredo, La Jolla, CA, 92037, USA. james.l.dudl@kp.org.
authors.forename: James
authors.initials: J
authors.lastname: Dudl
authors.affiliation: Kaiser Permanente Northwest Medical Group, 500 NE Multnomah Street, Suite 100, Portland, OR, 97232, USA. wiley.chan@kp.org.
authors.forename: Wiley
authors.initials: W
authors.lastname: Chan
authors.affiliation: OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA. devoej@ohsu.edu.|Oregon Health Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA. devoej@ohsu.edu.
authors.forename: Jennifer
authors.initials: J
authors.lastname: DeVoe
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage; D001241:Aspirin / Q000008:administration & dosage; D002317:Cardiovascular Agents / Q000008:administration & dosage*; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D003151:Community Health Centers / Q000458:organization & administration* / Q000592:standards; D048909:Diabetes Complications / Q000517:prevention & control; D003920:Diabetes Mellitus / Q000628:therapy*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D058996:Quality Improvement / Q000458:organization & administration*; D019984:Quality Indicators, Health Care; D064876:Safety-net Providers / Q000458:organization & administration* / Q000592:standards; D055815:Young Adult
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D002317:Cardiovascular Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D001241:Aspirin