A real-world stepped wedge cluster randomized trial of practice facilitation to improve cardiovascular care.
BACKGROUND
Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC's impact on adherence to processes of care delivery.


METHODS
A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada (ClinicalTrials.gov: NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention.


RESULTS
Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively.


CONCLUSIONS
IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice.


BACKGROUND
ClinicalTrials.gov NCT00574808.
C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. cliddy@bruyere.org.|Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada. cliddy@bruyere.org.|Bruyère Research Institute, 43 Bruyère St, Annex E, Room 106, Ottawa, Ontario, K1N 5C8, Canada. cliddy@bruyere.org.
Clare
C
Liddy
C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. whogg@bruyere.org.|Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada. whogg@bruyere.org.
William
W
Hogg
C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. jpsingh99@gmail.com.|Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada. jpsingh99@gmail.com.
Jatinderpreet
J
Singh
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. mtaljaard@ohri.ca.|Department of Epidemiology and Community Medicine, University of Ottawa, Ontario, Canada. mtaljaard@ohri.ca.
Monica
M
Taljaard
C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. grant.russell@monash.edu.|Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Notting Hill, Victoria, Australia. grant.russell@monash.edu.
Grant
G
Russell
Department of Economics, University of Ottawa, Ottawa, Ontario, Canada. cdarmstrong@uottawa.ca.
Catherine
C
Deri Armstrong
The Ottawa Hospital, Ottawa, Ontario, Canada. aakbari@toh.on.ca.
Ayub
A
Akbari
C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada. sdahrouge@bruyere.org.|Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada. sdahrouge@bruyere.org.
Simone
S
Dahrouge
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. jgrimshaw@ohri.ca.|Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada. jgrimshaw@ohri.ca.
Jeremy M
JM
Grimshaw
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration* / Q000592:standards; D058996:Quality Improvement / Q000458:organization & administration*