Identifying Practice Facilitation Delays and Barriers in Primary Care Quality Improvement

Jiancheng Ye; Renwen Zhang; Jennifer E. Bannon; Ann A. Wang; Theresa L. Walunas; Abel N. Kho; Nicholas D. Soulakis

doi:10.3122/jabfm.2020.05.200058

Article Figures & Data

Figures

Tables

Download figure
Open in new tab
Figure 1.
Workflow of practice facilitation in the Healthy Hearts in the Heartland (H3) initiative. Abbreviations: PF, practice facilitator; QB, QuickBase; NU, Northwestern University; ABCS, aspirin use, blood pressure, cholesterol, and smoking.
Download figure
Open in new tab
Figure 2.
Example practice (#117) activities and delays. This Figure illustrates the mechanism by which the 2 types of delays are identified. If the interval between activities (IBA) is higher than the Z-score (described in Methods, Step 2), a delay will be detected. X-axis is the sequence number of each activity; Y-axis is the number of days between activities; Mov_Avg is the moving average results of IBA; Mov_Avg 95% CI is the 95% confidence interval of the Mov_Avg results.
Download figure
Open in new tab
Download figure
Open in new tab

Tables

Figures

View popup

Table 1.

Characteristics of 226 Practices in Illinois, Wisconsin, and Indiana Participating in the Healthy Hearts in the Heartland (H3) Initiative across 4 Waves in 2016

Characteristics	N (%)
Number of practices by wave
Wave 1	42 (18.6)
Wave 2	40 (17.7)
Wave 3	67 (29.6)
Wave 4	77 (34.1)
Clinicians, n
Solo practice	67 (29.6)
2−5	103 (45.6)
6−10	34 (15.0)
11−15	10 (4.40)
16−20	12 (5.30)
State
Illinois	152 (67.3)
Wisconsin	22 (9.7)
Indiana	52 (23.0)

The 4 waves were the randomization conditions of the study. The waves determined when a practice started receiving the 12-month intervention. Practices in Wave 1 started from the first quarter of 2016; wave 2 started from the second quarter of 2016, and so on. The four waves were reported separately because the starting and end dates were different.

View popup

Table 2.

Characteristics of Two Types of Delays across the 4 Waves with a 12-Month Period

	Wave 1	Wave 2	Wave 3	Wave 4	Total
Total number of Delay I^*	84	44	142	131	401
Total number of Delay II^†	45	25	84	63	217
Median No. of Delay I per practice (IQR)	2 (1 to 3)	1 (0 to 2)	2 (1 to 3)	2 (1 to 2)	2 (1 to 3)
Median No. of Delay II per practice (IQR)	1 (0 to 2)	0 (0 to 1)	1 (0 to 2)	1 (0 to 1)	1(0 to 1)

IQR, interquartile range.
The 4 waves were reported separately because the starting and end dates were different.
↵* Delay I was calculated based on Z score > 1.282, which corresponds to a one-tailed 90% confidence interval. Delay I is identified if the interval between activities (IBA) deviates from the practice's normal pattern of facilitation activities.
↵† Delay II was calculated based on Z-score > 1.645, which corresponds to a one-tailed 95% confidence interval. Delay II captures a larger deviation from the normal pattern compared to Delay I. Delay I is more sensitive to detecting delays than Delay II and could capture more instances of infrequent facilitation activities.

View popup

Table 3.

Barriers to Practice Facilitation and Quality Improvement Intervention (Source: Practice Facilitators' Notes)

Domain	Barriers	N (%)
Practice-related barriers	Lack of time and staff	378 (44.37)
	EHR-related issues	136 (15.96)
	Lack of buy-in/engagement	133 (15.61)
	Other^*	59 (6.92)
	Staff turnover	51 (5.99)
	Workflow issues	29 (3.40)
Implementation-related barriers	Technical issues	37 (4.34)
	Lack of guidelines	12 (1.41)
	Lack of reimbursement	8 (0.94)
	Lack of language diversity of intervention materials	9 (1.06)

↵* Examples include low resources, lack of investment, clinic construction, patient issues, and logistic issues.
EHR, electronic health record.

View popup

Table 4.

Regression Analysis of Barriers on Two Types of Delays

Variable	Delay I	Delay II
Variable	Beta (95% CI)	Beta (95% CI)
Practice-related barriers
Lack of time & staff	0.16 (0.08, 0.24)^*	0.08 (0.02, 0.14)^*
EHR-related issues	0.29 (0.14, 0.44)^*	0.13 (0.02, 0.24)^†
Lack of buy-in/engagement	0.19 (0.01, 0.36)^†	0.15 (0.02, 0.27)^†
Staff turnover	0.48 (0.15, 0.82)^*	0.31 (0.06, 0.55)^†
Workflow issues	0.06 (−0.37, 0.48)	0.20 (−0.10, 0.51)
Other	0.26 (−0.04, 0.56)	0.15 (−0.07, 0.36)
Implementation-related barriers
Technical issues	0.18 (−0.23, 0.60)	0.04 (−0.36, 0.34)
Lack of guidelines	0.55 (−0.25, 1.34)	0.10 (−0.48, 0.67)
Lack of reimbursement	0.59 (−0.46, 1.64)	0.54 (−0.21, 1.29)
Lack of language diversity of intervention materials	0.61 (−0.20, 1.43)	0.25 (−0.34, 0.84)

EHR, electronic health record; CI, confidence interval.
↵* Significant at P < .01.
↵† Significant at P < .05.

View popup

Appendix A.

Practice Intervention Tracking Items

Intervention ID	Category	Measure	Component
1	A. Point-of-Care Clinical Decision Support	Aspirin	Reminder to order aspirin/antiplatelet drug for pts with IV.D (or CVD)
2	A. Point-of-Care Clinical Decision Support	BP	Alert staff to a patient with uncontrolled blood pressure
3	A. Point-of-Care Clinical Decision Support	Cholesterol	Alert for a lipid panel (or cholesterol) in ASCVD (or IV.D, or CVD)
4	A. Point-of-Care Clinical Decision Support	Cholesterol	Alert for a lipid panel (or cholesterol) in diabetes mellitus
5	A. Point-of-Care Clinical Decision Support	Cholesterol	Alert for a lipid panel in general population (low risk patients)
6	A. Point-of-Care Clinical Decision Support	Cholesterol	Reminder to order a statin in ASCVD (or IV.D, or CVD)
7	A. Point-of-Care Clinical Decision Support	Cholesterol	Reminder to order statin in diabetic patients
8	A. Point-of-Care Clinical Decision Support	Cholesterol	Alert to order a statin in pts with LDL 190
9	A. Point-of-Care Clinical Decision Support	Cholesterol	Alert to order statin in general population with increased risk (based on a risk calculator)
10	A. Point-of-Care Clinical Decision Support	Aspirin	Reminder to order aspirin for primary prevention in appropriate patients
11	A. Point-of-Care Clinical Decision Support	Smoking	Reminder for intervention in tobacco users or smokers
12	B. Other Clinical Decision Support Activities	BP	Orders/patient instructions/patient education for home BP monitoring
13	B. Other Clinical Decision Support Activities	Cholesterol	Patient education on cholesterol and/or cholesterol treatment
14	B. Other Clinical Decision Support Activities	Cholesterol	Standing orders for lipid profiles
15	B. Other Clinical Decision Support Activities	Smoking	Patient education on tobacco cessation
16	C. Practice Workflows	BP	Blood pressure measurement protocol
17	C. Practice Workflows	BP	Blood pressure treatment protocol
18	C. Practice Workflows	BP	Workflow for patient to report home blood pressures
19	C. Practice Workflows	Smoking	Tobacco use/smoking assessment part of intake or rooming process
20	C. Practice Workflows	Smoking	Clinic based tobacco use/smoking interventions
21	D. Reports on ABCS Performance	Aspirin	Metric for use of aspirin or another antithrombotic therapy in IV.D
22	D. Reports on ABCS Performance	BP	Metric for blood pressure control among patients with hypertension
23	D. Reports on ABCS Performance	Cholesterol	Metric for cholesterol treatment or control
24	D. Reports on ABCS Performance	Smoking	Metric for tobacco use assessment and brief intervention
25	E. Lists of Patients Not Meeting ABCS Measures	Aspirin	List of patients with IV.D not meeting aspirin/antithrombotic measure
26	E. Lists of Patients Not Meeting ABCS Measures	BP	List of patients with uncontrolled blood pressure
27	E. Lists of Patients Not Meeting ABCS Measures	Cholesterol	List of patients needing cholesterol measurement and/or treatment
28	E. Lists of Patients Not Meeting ABCS Measures	Smoking	List of tobacco users/smokers
29	F. Population Management Outreach	Aspirin	Outreach to patients with IV.D not on aspirin or another antithrombotic
30	F. Population Management Outreach	BP	Outreach to patients with uncontrolled hypertension
31	F. Population Management Outreach	Cholesterol	Outreach to patients who need cholesterol measurement or statin prescription
32	F. Population Management Outreach	Smoking	Outreach to tobacco users or smokers
33	F. Population Management Outreach	Cholesterol	Outreach to patients with increased CVD risk who are not on a statin for primary prevention
34	G. Population Management Community Resources	BP	Referral to community pharmacist for hypertension medication management
35	G. Population Management Community Resources	Other	Referral to HealtheRx resource

BP, blood pressure; LDL, low-density lipoprotein; CVD, cardiovascular disease; ASCVD, atherosclerotic cardiovascular disease; IVD, Ischemic vascular disease.

View popup

Appendix B.

Codebook for Qualitative Analysis

Id	Code	Sub-Codes
1–Practice-related barriers
1-1	Lack of time/staff	Scheduling issues Providers/Staff were busy/on vacation/personal issues (e.g., family emergency) Competing demands/priorities Limited time for QI activities Lack of staff/staff burnout
1-2	Lack of buy-in/engagement	Providers negative attitudes/belief Lack of engagement/leader support/interest
1-3	EHR-related issues	EHR update/change Outdated EHR/data infrastructure Facilitators had no access to EHR
1-4	Other	Low resources Lack of investment Patient issue Clinic construction Logistic issues
1-5	Staff turnover	Staff turnover
1-6	Workflow issues	Clinical workflow Teamwork/Collaboration issues Communication inefficiency
2–Implementation-related barriers
2-1	Technical issues	Delays in data extraction/access Lack of proper document, such as BAA
2-2	Lack of guidelines	Lack of guidance on EHR documentation Insufficient guidelines on data extraction
2 to 3	Lack of reimbursement	Lack of reimbursement
2 to 4	Lack of language diversity of intervention materials	Most intervention materials are in English