Research article
Sustainability of a practice-individualized preventive service delivery intervention

https://doi.org/10.1016/S0749-3797(03)00219-8Get rights and content

Abstract

Background

The long-term effect of most interventions has not been studied. Changes due to interventions to improve patient care may revert to baseline after the intervention stimulus ends. This analysis reports the 24-month follow-up of a practice-tailored intervention to increase preventive service delivery rates.

Design

Group randomized clinical trial with 24-month follow-up of intervention sites.

Setting/participants

Seventy-seven community family practices in northeast Ohio.

Intervention

Practice-individualized facilitation of implementation of tools and approaches.

Main outcome measures

Summary scores of health habit counseling, screening, and immunization services recommended by the U.S. Preventive Services Task Force that were up to date for consecutive patients during randomly selected chart review days.

Results

Previously reported increases in global preventive service delivery rates, health habit counseling, and screening rates at 12 months were sustained after 24 months.

Conclusions

A practice-individualized approach can result in sustainable increases in rates of preventive service delivery, even 1 year after the outside intervention stimulus ends. Tailoring of approaches to the unique characteristics of each practice may result in institutionalization of changes.

Introduction

P reviously in this journal, the authors reported the results of a clinical trial of a practice-individualized approach to increase preventive service delivery rates.1 The trial, called STEP-UP (Study To Enhance Prevention by Understanding Practice), resulted in increases in a global measure of preventive service delivery and in subscores for health habit counseling and screening. Increases in immunization rates were not statistically different from baseline. In this article, an additional 12 months of follow-up of the study's intervention group were analyzed to assess if the effect was sustainable after the intervention stimulus ended.

The sustainability of the effect of an intervention to increase preventive service delivery is of interest for two reasons. First, few interventions have been subjected to long-term analysis of effectiveness.2, 3 Second, concern exists that intervention effects may diminish over time once the stimulus for change is gone3, 4, 5, 6 and once competing demands7, 8 and inertia9 divert time and energy toward other activities. Initial implementation success does not predict institutionalization of outcome changes.2 If changes are due to an outside stimulus, usual patterns of activity will result in pressures to return to previous ways of operating10 once the intervention inducement for change is gone.

However, an intervention that is tailored to the unique characteristics of each practice may be more likely to become incorporated into the structure and function of day-to-day operations and, as a result, may become independent of the outside intervention. Therefore, the sustainability of the previously successful STEP-UP intervention was examined.

Section snippets

Methods

The methods of the STEP-UP trial have been previously described in detail.1 Briefly, this main effects–group–cross-sectional–randomized trial involved 79 family practices in Northeast Ohio. Practices were randomized to an intervention (n=39) or a control group (n=40). After 1 year of follow-up, the control practices were presented with a refined intervention and are, therefore, excluded from this analysis. Of the 39 practices in the initial intervention group, 38 completed the initial 12 months

Results

As described previously,1 36% of practices were solo; the rest ranged from two to nine physicians. Figure 1 shows that the increase in global rates of preventive service delivery in the intervention group during the 1-year intervention period was sustained during the 1-year period after the intervention concluded. Table 1 shows the rates of delivery of preventive services assessed by the global measure and the subscales for health habit counseling, screening, and immunization services. The p

Discussion

This follow-up analysis of a rigorous clinical trial of community practices shows that the effects of an intervention to increase preventive service delivery can be sustained for at least 1 year after the direct intervention ends. The authors believe that this continued effect is likely due to the practice-individualized approach during the intervention. A tailored intervention is more likely to become institutionalized into the usual routines of the practice than an intervention approach that

Acknowledgements

The authors are grateful to the physicians, office staffs, and patients, without whose participation this study would not have been possible. This research was supported by grants from the National Cancer Institute (2R01 CA80862, K24 CA81031) and a family practice research center grant from the American Academy of Family Physicians.

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