Article Figures & Data
Tables
- Table 1.
Local Learning Collaborative (LLC) Formation and Availability of Data by Practice-based Research Network (PBRN)
Total PBRN LaNET MAFPRN OKPRN WREN LLC formed* 30 8 7 8 7 LLC met at least once 20 0 5 8 6 Coordinator summaries 4 Yes Yes Yes Yes Implementation outcomes assessed** 3 NA Yes Yes Yes Intervention fidelity assessed*** 2 NA NA Yes Yes Clinician perspectives 2 NA NA Yes Yes ↵* LLC officially formed consisting of one representative from Wave I practice and a representative from each of the two Wave II practices.
↵** LLC implementation occurred in three of four PBRNs.
↵*** Two of three PBRNs collected complete meeting minutes from which fidelity outcomes were extracted. Clinicians from these two PBRNs participated in the interviews.
- Table 2.
Implementation Outcomes Representing Intervention Conduct and Fidelity for Three LLCs. (N = 20 LLCs, 3 PBRNs)
Implementation outcome Overall (N = 20) PBRN MAFPRN (N = 5)* OKPRN (N = 8) WREN (N = 7) No. of LLC meetings 121 31 48 42 No. of LLCs with at least 6 meetings 19 5 8 6 No. of unique participants 210 46 56 108 No. of clinician participants 112 (53%) 30 (65%) 38 (68%) 44 (41%) ↵* Data on implementation outcomes was not available for two MAFPRN LLCs.
LLC, local learning collaborative; PBRN, practice-based research network.
- Table 3.
Practice-based Research Network (PBRN) Coordinator Perspectives on Local Learning Collaborative (LLC) Feasibility
Coordinator statement LaNet ■ Despite initial success at launching several LLCs (had at least one meeting), they were not sustainable. Lack of a critical mass of participants including the Wave I expert resulted in discussions that were superficial and of minimal use, leading to a decrease in enthusiasm for future participation. The primary barrier was the demands of patient care, as clinicians had limited control of schedules, and clinics were often understaffed as all were federally qualified health centers. In response, LANet offered virtual LLCs on a standing bi-weekly schedule, inviting all LANet site champions (not just those originally in the LLC), and arranging for a primary care physician who was expert in CKD to provide perspective on clinical care and guideline implementation. While maintaining continuity across sessions through agendas and minutes was not feasible, LANet created a central database for information on practice goals and progress that was updated after each session. This information was used by the LANet meeting facilitator to stimulate discussion and encourage sharing of lessons learned. These modifications increased participation as well as participant satisfaction. MAPRN ■ MAFPRN formed seven LLCs (14 practices; six in urban settings, six in rural settings, and two in the suburbs). Many Minnesota clinicians are familiar with sharing and discussing performance data, based on several years of QI strategy discussions based on data available to health systems and the public. While LLCs were open to administrators and other staff, they were only in attendance at the three in-person LLCs, compared to the four using web-based meetings due to distance between practices. Web-based meetings, especially among clinicians unknown to each other, appeared to decrease the sense of urgency generated through in-person meetings, with attendance likely suffering. For these meetings the PF was on site with a Wave II practice, and scheduled additional meetings with staff to provide further information as needed. As large health systems dominate care delivery in Minnesota, a challenge to participation was lack of alignment between health system and PBRN research priorities. Overall, the LLC experience for MAFPRN clinicians was useful for improving CKD patient care. OKPRN ■ Half of OKPRN's eight LLCs were located in rural/small cities and others were mostly suburban. For three of the LLCs, the close proximity of the practices provided easy access to meetings, as practices were either in the same building or nearby. Three others shared the same health system infrastructure, with system modifications shared more easily among practices. Most meetings were scheduled in-person, however due to the press of patient care and other competing demands, only those in close proximity managed to attend and to bring other staff members with them. For others, conference calling was the usual default that allowed at least some participation. Meetings were usually scheduled at lunch time, planned and organized by the PF, and included lunch purchased by the Wave I clinician if the meeting was in person. The PF typically rotated attendance at one of the practices. Early sessions were recorded (with permission) to assess adherence to the meeting protocol and general direction of discussions. Two factors supported successful LLCs: prior personal relationships and geographic proximity. Most clinicians were known to each other and brought these relationships as an asset to LLC meetings. When prior relationships did not exist, LLCs were formed based on either common medical system or use of the same EHR. Practices close geographic proximity had the best attendance rates and staff participation, and in-person meetings compared to conference calls were easier to maintain over time. WREN ■ Seven LLCs formed by WREN were a mix of rural and urban practices; not enough practices were recruited to form the eighth. Four were comprised of members of the same health care system or were co-located and able to meet in person. Geographic spread for the other three was too large for in-person meetings to be feasible, so they met using telephone conferencing. Although videoconference and Skype were attempted, they were not favored and were discontinued. Positive aspects of LLC participation included sharing of successes by Wave I clinicians with other LLC participants that resulted in implementation of these strategies within the Wave II practices. For example, a patient education document developed by an inner-city Wave I clinic was shared with all WREN practices and other participating PBRNs. Additional help was provided by the sharing of EHR enhancements and these continued after the project ended. Barriers to LLC success included both PF and leadership turnover. Two Wave I PFs and the original project coordinator were unavailable during Wave II, and this essential continuity was lost. In addition, some Wave I practices were more actively involved recruiting for the LLCs, which resulted in only seven successfully formed. For many practices this was their first WREN project, which meant that PBRN staff were facilitating the intervention at the same time they were building new relationships with staff. Thus, some of the intervention strategies were delayed and may not have had sufficient time to impact change in outcomes. CKD, chronic kidney disease; QI, quality improvement; EHR, electronic health record.
- Table 4.
Fidelity Outcomes by Practice-based Research Network (PBRN) (N = 15 LLCs, 2 PBRNs)
Fidelity outcomes Total OKPRN WREN No. of LLC meetings 90 48 42 No. with all practices present (meetings) 71 (79%) 37 (77%) 34 (81%) No. with Wave I clinician present (meetings) 74 (82%) 46 (96%) 28 (67%) No. with performance data (meetings) 61 (68%) 35 (73%) 26 (62%) LLC, local learning collaborative.
Guidelines Total PBRN OKPRN WREN Number of practices, N 45 24 21 Guidelines worked on at least once, Range 3 to 6 4 to 6 3 to 6 Patient education, N (%) 39 (87%) 18 (75%) 21 (100%) CKD diagnosis on problem list, N (%) 36 (80%) 16 (67%) 20 (95%) Addition of appropriate meds, N (%) 35 (78%) 20 (83%) 15 (71%) Removal of inappropriate meds, N (%) 31 (69%) 20 (83%) 11 (52%) Ordering of appropriate labs, N (%) 26 (58%) 19 (79%) 7 (33%) eGFR in patient charts, N (%) 25 (56%) 8 (33%) 17 (81%) CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; LLC, local learning collaborative; PBRN, practice-based research network.
Reaction Sharing the same EHR ■ … “made a big difference. One of the biggest challenges is dealing with different EHRs. Knowing that we are all the same that way, because one little change can throw things off, even different sites that are the same clinic may have different SmartSets.” ■ … “made it slightly easier in terms of talking about quality improvement or a workflow, especially trying to facilitate improvements with the EHR, everyone knows how it would work.” ■ “It's nice to share information, but to share monthly meetings with both clinics didn't make any sense because they were so different.” Belonging to the same practice group ■ “I think the fact that we were all from the same company, we all have the same difficulties with our patients. I think that helped us as far as being able to make suggestions to know what the other is going through and roadblocks we encounter.” ■ … “there's a certain level of comfort [among members of the same group], people are more open to share their opinions.” Key success factors Sharing performance data ■ … “When you look at your own stats, you always think that they are going to be better than they are. And when you don't see it that way, you ask what you can do better.” ■ “We learned that there is a lot more we can do and have to be more attentive,” and “ … always good to see your data, and see how you stand… . hopefully motivation to keep improving.” ■ “When you saw the numbers at the end and compared to the other clinics that was helpful because there is always a little competition I guess, which motivates staff at times.” Reaction Team support ■ “From my site, I was the only one who consistently took the time… . you got to have the key players at the table, but I would think two or three so it feels like a team effort.” Satisfaction and sustainability ■ “First experience, really enjoyed it.” ■ “It was really good. I'll see about signing up for another wave.” ■ “The project itself went well. The only thing now is keeping it going, the list updated, staying on top of CKD.” ■ “Didn't have the tools to keep the changes going long-term. Good for short-term. To affect patient care, needs to be implemented longer-term; don't have the tools to do that. Still don't today.” Change in knowledge, skills, and attitudes CKD knowledge and skills ■ “I was shocked at how many patients fall into mild CKD, where their creatinine levels were normal, but their GFRs were low.” ■ “Just having it on the problem list with all my patients has really changed my practice.” ■ “We have so many diabetics on metformin, but I didn't make it a priority to check.” ■ “[It] helped keep staff and me more focused on what we're doing… . it helped us develop strategies to incorporate in daily work.” Priority for improving CKD care ■ “It also made me much more confident that I knew what to look for and had some clue about what to do with what I found.” ■ “… definitely made a difference in terms of my priority. I wasn't really clear about the management and treatment and identification of CKD. And this study really put things in focus when we discussed the numbers [feedback reports].” CKD, chronic kidney disease; EHR, electronic health record; GFR, glomerular filtration rate.
