Implementation of Asthma Guidelines in Primary Care; Comparison of 4 approaches

描述（由申请人提供）：自1991年以来，执业医生就可以使用循证哮喘管理指南1.1随机对照临床试验表明，实施哮喘指南建议可以显著改善所有年龄段哮喘患者的患者水平结果。然而，在初级保健实践中，指南建议的采纳和实施仍然不一致和不平衡。指导方针的实施具有挑战性。仅靠临床医生教育和工具包等简单策略通常是不够的。重大的广泛和持久的改善将需要可推广的干预措施，以增加变革的动机和能力，并注重改变护理过程。这些干预措施必须对初级保健实践是可行和可接受的。像实践促进（PF）这样的干预措施增加而不是消耗实践资源，以及本地学习合作（LLC），在实践之间产生竞争和合作，已经显示出希望，但需要进一步研究。我们建议对单独或联合提供的PF和LLC进行2 × 2因子（四组）、混合方法、聚类随机对照试验（RCT），与单独提供的哮喘指南和工具包加绩效反馈（GTF）进行比较，以测试这些干预措施在初级保健实践中实施最新的国家心肺血液研究所认可的哮喘指南的有效性和可接受性。具体目标是：目标1（系统级效应）：评估建议的干预措施——GTF、PF、LLC以及PF和LLC的组合——对实践变化的三个关键组成部分的影响，具体变化的优先级、变化过程能力（变化的能力）和关注过程内容（指南实施所需的过程中的具体变化）；目标2（指南水平效应）：比较四种实施干预措施的有效性——A) GTF， B) GTF加PF， C) GTF加LLC， D) GTF、PF和LLC——在实践中实施NHLBI哮喘指南的六个关键信息；目标3（调节者）：测试关键实践特征——电子健康记录的使用（Y/N）、中级临床医生的存在（Y/N）、实践所有权（临床医生拥有Y/N）和实践中临床医生数量（#）——指南实施之间的关系。公共卫生相关性：相关性声明如果在全美国的初级保健实践中实施循证哮喘管理指南，我们可以分别减少56%和91%的门诊和急诊室就诊。该项目将提供有价值的信息，使我们能够评估四种实践改变策略的有效性，以改善哮喘指南在初级保健实践中的实施。如果有效，同样的战略可用于促进其他慢性病指南的实施。

DESCRIPTION (provided by applicant): Evidence-based guidelines for asthma management have been available to practicing physicians since 1991.1 Randomized controlled clinical trials have demonstrated that implementation of asthma guideline recommendations can significantly improve patient- level outcomes in asthmatics of all ages. However, in primary care practices, adoption and implementation of guideline recommendations continues to be inconsistent and uneven. Implementation of guidelines is challenging. Simple strategies like clinician education and toolkits alone are usually insufficient. Significant widespread and long- lasting improvements will require generalizable interventions that increase motivation and capacity for change and focus on changing processes of care. These interventions must be feasible and acceptable to primary care practices. Interventions like practice facilitation (PF), which add to rather than deplete practice resources, and local learning collaboratives (LLC), which produce competition and collaboration between practices have shown promise but require further study. We propose to conduct a 2 x 2 factorial (four-arm), mixed-method, cluster randomized controlled trial (RCT) of PF and LLC, provided individually and in combination, compared to provision of the asthma guidelines and a toolkit plus performance feedback (GTF) alone, to test the effectiveness and acceptability of these interventions for implementation of the most recent National Heart Lung and Blood Institute-endorsed asthma guideline in primary care practices. The specific aims are: Aim 1 (System-Level Effects): Evaluate the impacts of the proposed interventions -- GTF, PF, LLC, and the combination of PF and LLC -- on three key components of practice change, priority for the specific changes, change process capability (capacity to change), and care process content (the specific changes in process required for guideline implementation); Aim 2 (Guideline-Level Effects): Compare the effectiveness of four implementation interventions -- A) GTF, B) GTF plus PF, C) GTF plus LLC, and D) GTF, PF, and LLC -- on the practices' implementation of the six key messages of the NHLBI asthma guidelines; and Aim 3 (Moderators): Test the relationships between key practice characteristics -- use of electronic health records (Y/N), presence of mid-level clinicians (Y/N), practice ownership (clinicians own Y/N), and number of clinicians in the practice (#) -- guideline implementation. PUBLIC HEALTH RELEVANCE: Statement of Relevance If evidence-based guidelines for asthma management were implemented in primary care practices throughout the United States, we could reduce outpatient and emergency room visits by 56% and 91% respectively. This project will provide valuable information that will allow us to evaluate the effectiveness of four practice change strategies to improve asthma guideline implementation in primary care practices. If effective, the same strategies could be used to facilitate implementation of other chronic disease guidelines.