Deborah J. Cohen, PhD; Bijal A. Balasubramanian, MBBS, PhD; Stephan Lindner, PhD; William L. Miller, MD, MA; Shannon M. Sweeney, PhD, MPH; Jennifer D. Hall, MPH; Rikki Ward, MPH; Miguel Marino, PhD; Rachel Springer, MS; K. John McConnell, PhD; Jennifer Hemler, PhD; Sarah S. Ono, PhD; David Ezekiel-Herrera, MS; Andrea Baron, MPH; Benjamin F. Crabtree, PhD; Leif I. Solberg, MD
Corresponding Author: Deborah J. Cohen, PhD; Department of Family Medicine (primary) and Department of Medical and Clinical Epidemiology (secondary) - Oregon Health & Science University.
Contact Email: cohendj@ohsu.edu
Section: Original Research
Ahead of Print Version: www.jabfm.org/content/early/2022/09/15/jabfm.2022.AP.220088
Final Publication: www.jabfm.org/content/35/6/1115
PURPOSE: Examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care.
METHODS: Mixed-methods study of seven EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (N=1,720). Independent Variable: Extent to which (QI) prior to EvidenceNOW, including leaders with experience implementing support and infrastructure to support it (high, medium or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices’ performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS) and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach.
RESULTS: Cooperatives with High (vs. low) levels of prior experience with and investment in large-scale QI prior to EvidenceNOW recruited more geographically-dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, p=0.040), and made greater improvements in practices’ QI capacity (CPCQ: +2.04, p<0.001) and smoking performance (+6.43%, p=0.0030). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes.
CONCLUSION: Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.