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

 描述（由申请人提供）：在初级保健机构，特别是为低收入和少数民族人群服务的机构，预防心血管疾病（CVD）指南的实施不足，导致CVD相关发病率和死亡率的持续差异。本提案的目的是通过测试实践促进作为一种质量改进策略的有效性来填补目前研究与实践之间的空白，该策略用于实施循证指南，以减少纽约市初级保健实践中的心血管疾病相关风险因素。该提案的具体重点是提高对ABCS的依从性-高风险个体的阿司匹林（A）、血压控制（B）、胆固醇管理（C）和戒烟（S）。长期目标是建立一个强有力的基础设施，以便在初级保健实践中传播和实施以患者为中心的成果研究结果，并提高实践在未来实施以患者为中心的成果研究其他结果的能力。最近的系统评价表明，在促进实施循证研究的干预措施已被证明是有效的，是量身定制的实践背景下，并涉及基于慢性病护理模式（CCM）的多组分方法。然而，大多数实践缺乏资源和专门知识，无法在没有援助的情况下协调一系列复杂的多级系统更改。一个可以有效克服这些障碍的实施战略是实践促进。PF提供与CCM雅阁的实践重新设计方面的外部专业知识，并促进实施指南一致性护理的定制方法，以改善患者结局。因此，我们建议通过采用阶梯楔形设计研究PF对CVD相关结局的影响，其中250个EHR启用的中小型初级保健站点同时入组对照组，然后随机分配以三个月的间隔交叉进入干预条件，所有站点最终接受干预。主要结局是达到ABCS临床目标的患者比例。NYUSOM和纽约市卫生部（NYCDOH）初级保健改善计划（PCIP）之间的独特伙伴关系增强了这一建议的重要性和大规模传播研究结果的潜力，在其区域推广中心和纽约州社区卫生保健协会（CHCANYS）中有3000多个中小型初级保健实践，全国首屈一指的非营利初级保健协会之一。该提案利用了PCIP和CHCANY强大的信息技术基础设施及其集中式数据仓库提供的效率，这些数据仓库具有跨不同环境收集不同EHR数据的能力。该项目预计将提供关键的新知识，以促进在美国广泛实施，传播和持续利用基于证据的CVD预防指南。

 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.