Practice Outcomes in Community & Healthcare Systems

描述(由申请人提供)：初级保健实践位于独特的位置，为大多数美国人提供有效的预防服务。然而，由于大多数实践的改变能力有限，并且与系统和社区资源隔绝，这一潜力尚未得到发挥。 我们之前的研究已经建立了一个社区实践实验室，用于癌症控制研究。在观察性研究中，我们发现了新的实践机会--加强预防的个体化方法。将这些见解应用于Step-Up临床试验，证明了预防性服务提供的可持续增长。对高变化实践和低变化实践的多方法过程评估产生了一个多层次、多阶段干预的新模型，该模型涉及实践、社区和医疗保健系统资源。 建议的竞争性继续试验是一项群组随机临床试验。按卫生保健系统隶属关系分层的30个初级保健实践将随机分为初始干预组或延迟干预组。 干预首先对每个实践及其社区和医疗保健系统的改变能力进行多方法评估。这项评估的见解将为建设实践、改变能力以及社区和卫生保健系统联系的参与性方法提供参考。然后，这些新的能力和联系将被用来量身定做提供预防性服务的可持续办法。 干预措施的假设效果将根据以下几个方面进行评估：实践的改变能力、美国预防服务工作组建议的预防服务的交付速度以及患者和临床医生的满意度。将使用多水平建模来控制分组和组之间的任何基线差异。 使用一套创新的多方法程序，将评估变化的过程。由此得到的见解将被用来设计一种精细化的多层次干预。延迟干预组将采用事后设计实施和评估这一改进的干预措施，而初始干预组将继续评估长期结果。由此产生的知识将被转移到寻求提高卫生保健质量的其他系统。

DESCRIPTION (provided by applicant): Primary care practices are uniquely situated to deliver effective preventive services to the majority of Americans. However, because of most practices' limited capacity to change and isolation from systems and community resources, this potential has not been met. Our prior research has developed a community practice laboratory for cancer control research. In observational studies we discovered novel opportunities for practice-individualized approaches to enhancing prevention. Applying these insights in the STEP-UP clinical trial demonstrated sustainable increases in preventive service delivery. Multimethod process assessments of high and low change practices produced a new model for a multilevel, multistage intervention that engages practice, community and healthcare system resources. The proposed competing continuation project is a group randomized clinical trial. Thirty primary care practices, stratified by health care system affiliation, will be randomized to initial or delayed intervention groups. The intervention begins with a multimethod assessment of the capacity to change of each practice and its community and healthcare system. Insights from this assessment will inform a participatory approach to building practice change capacity and community and health care system linkages. These new capacities and connections will then be used to tailor sustainable approaches to preventive service delivery. The hypothesized effects of the intervention will be assessed on: practices' capability for change, rate of delivery of US Preventive Services Task Force-recommended preventive services, and patient and clinician satisfaction. Multilevel modeling will be used to control for clustering and any baseline differences between groups. Using an innovative set of multimethod procedures, the process of change will be assessed. The resulting insights will be used to design a refined multilevel intervention. This refined intervention will be implemented and evaluated in the delayed intervention group using a pre-post design, while long-term outcomes continue to be assessed in the initial intervention group. The resulting knowledge will be transportable to other systems seeking to improve the quality of health care.