Practice facilitation for improving cardiovascular care: secondary evaluation of a stepped wedge cluster randomized controlled trial using population-based administrative data.
Practice facilitation (PF), a multifaceted approach in which facilitators (external health care professionals) help family physicians to improve their adoption of best practices, has been highly successful. Improved Delivery of Cardiovascular Care (IDOCC) was an innovative PF trial designed to improve evidence-based care for people who have, or are at risk of, cardiovascular disease (CVD). The intervention was found to be ineffective as assessed by a patient-level composite score based on chart reviews from a subsample of patients (N = 5292). Here, we used population-based administrative data to examine IDOCC's effect on CVD-related hospitalizations.



IDOCC used a pragmatic, stepped wedge cluster randomized controlled design involving primary care providers recruited across Eastern Ontario, Canada. IDOCC's effect on CVD-related hospitalizations was assessed in the 2 years of active intervention and post-intervention years. Marginal and mixed-effects regression analyses were used to account for the study design and to control for patient, physician, and practice characteristics. Secondary and subgroup analyses investigated robustness.



Our sample included 262,996 patient/year observations representing 54,085 unique patients who had, or were at risk of, CVD, from 70 practices. There was a strong decreasing secular trend in CVD-related hospitalizations but no statistically significant effect of IDOCC. Relative to patients in the control condition, patients in the intervention condition were estimated to have 4 % lower odds of CVD-related hospitalizations (adjOR = 0.96, 99 % CI 0.83 to 1.11). The nonsignificant result persisted across robustness analyses.



Clinical outcomes from administrative databases were examined to form a more complete picture of the (in)effectiveness of a large-scale quality improvement intervention. IDOCC did not have a significant effect on CVD hospitalizations, suggesting that the results from the primary composite adherence score analysis were neither due to choice of outcome nor relatively short follow-up period.



ClinicalTrials.gov NCT00574808 , registered on 14 December 2007.
Department of Economics, University of Ottawa, Ottawa, ON, Canada. cdarmstrong@uottawa.ca.
Catherine
C
Deri Armstrong
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.|Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.
Monica
M
Taljaard
C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.|Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.|Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada.
William
W
Hogg
Institute for Clinical Evaluative Sciences, Ottawa, ON, Canada.|Ottawa Hospital Research Institute, Ottawa, ON, Canada.
Amy E
AE
Mark
C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.|Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
Clare
C
Liddy
D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000628:therapy*; D016208:Databases, Factual; D019033:Delivery of Health Care, Integrated / Q000592:standards*; D019983:Guideline Adherence; D006302:Health Services Research; D006760:Hospitalization; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D016017:Odds Ratio; D009864:Ontario; D010348:Patient Care Team / Q000592:standards; D010821:Physicians, Family / Q000592:standards*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D011320:Primary Health Care / Q000592:standards*; D017064:Process Assessment, Health Care; D058996:Quality Improvement / Q000592:standards*; D019984:Quality Indicators, Health Care / Q000592:standards*; D012107:Research Design; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
Cardiovascular health; Practice facilitation; Primary care