Using practice facilitation in primary care settings to reduce risk factors for cardiovascular disease

 说明(申请人提供)：在初级保健环境中，特别是在为低收入和少数群体服务的环境中，没有充分执行预防心血管疾病的指导方针，导致与心血管疾病相关的发病率和死亡率持续悬殊。这项建议的目的是通过测试实践便利化作为一种质量改进战略的有效性来填补目前研究与实践之间的差距，以实施基于证据的指南，以减少纽约市初级保健实践中与心血管疾病相关的风险因素。这项建议的具体重点是提高高危人群对ABCS-阿司匹林(A)、血压控制(B)、胆固醇管理(C)和戒烟(S)的依从性。长期目标是创建一个强大的基础设施，在初级保健实践中传播和实施以患者为中心的结果研究(PCOR)结果，并提高实践在未来实施其他PCOR结果的能力。最近的系统审查表明，在促进实施循证研究方面被证明有效的干预措施是根据实践背景量身定做的，并涉及基于慢性护理模式(CCM)的多组成部分方法。然而，大多数实践缺乏资源和专业知识，无法在没有帮助的情况下协调一组复杂的多级别系统更改。一种可以有效克服这些障碍的实施战略是实践促进(PF)。PF提供符合CCM的实践重新设计的外部专业知识，并促进实施与指南一致的护理以改善患者预后的量身定制的方法。因此，我们建议采用阶梯式楔形设计来研究PF对心血管疾病相关结局的影响，在该设计中，250个启用EHR的中小型初级保健站点同时登记到对照组中，然后随机分配到每隔三个月交叉进入干预条件，所有站点最终都接受干预。主要结果是达到ABCSs临床目标的患者比例。这项建议的重要性和大规模传播研究结果的潜力因NYUSOM与纽约市卫生部(NYCDOH)初级保健改善计划(PCIP)之间的独特合作关系而得到加强，PCIP在其地区推广中心和纽约州社区保健协会(CHCANYS)之间拥有3000多家中小型初级保健诊所，CHCANYS是美国主要的非营利性初级保健协会之一。该提案利用了PCIP和CHCANY强大的信息技术基础设施，以及由其中央数据仓库提供的效率，这些数据仓库具有跨不同环境和不同EHR收集数据的能力。该项目预计将提供关键的新知识，以促进在美国各地广泛实施、传播和持续使用以证据为基础的预防心血管疾病指南。

 DESCRIPTION (provided by applicant): Inadequate implementation of guidelines for prevention of cardiovascular disease (CVD) in primary care settings, particularly those serving low-income and minority populations, has contributed to persistent disparities in CVD-related morbidity and mortality. The objective of this proposal is to fill this current research-to-practic gap by testing the effectiveness of practice facilitation as a quality improvement strategy for implementing evidence-based guidelines for reducing CVD-related risk factors in primary care practices in New York City. The specific focus, of this proposal is to improve adherence to the ABCS - Aspirin (A) in high-risk individuals, Blood pressure control (B), Cholesterol management (C), and Smoking cessation (S). The long-term goal is to create a robust infrastructure to disseminate and implement Patient Centered Outcomes Research (PCOR) findings in primary care practices and improve practices' capacity to implement other PCOR findings in the future. Recent systematic reviews demonstrate that interventions with proven effectiveness in promoting the implementation of evidence-based research are tailored to the practice context and involve a multicomponent approach based on the Chronic Care Model (CCM). Most practices, however, lack the resources and expertise to coordinate a complex set of multilevel system changes without assistance. One implementation strategy that may effectively overcome these barriers is practice facilitation (PF). PF provides external expertise on practice redesign i accord with the CCM, and promotes a tailored approach to implementing guideline-concordant care to improve patient outcomes. We therefore propose to study the impact of PF on CVD-related outcomes by employing a stepped-wedge design in which 250 EHR-enabled small to medium primary care sites are enrolled into the control at the same time and then randomly assigned to cross over into the intervention condition at three month intervals with all sites eventually receiving the intervention. The primary outcome is the proportion of patients that have reached clinical goals for the ABCSs. The significance of this proposal and potential for large-scale dissemination of findings is enhanced by the unique partnership between NYUSOM, and the NYC Department of Health (NYCDOH) Primary Care Improvement Program (PCIP), with over 3000 small to medium sized primary care practices in their regional extension center and the Community Health Care Association of New York State (CHCANYS), one of the premiere not-for-profit primary care associations in the country. The proposal leverages PCIP and CHCANY's robust information technology infrastructure and efficiencies offered by their centralized data warehouses with capacity for data collection across diverse settings with different EHRs. The project is expected to provide critical new knowledge to facilitate the widespread implementation, dissemination and sustained utilization of evidence- based guidelines for prevention of CVD across the U.S.