Patient care staff completing questionnaires included registered nurses (33%), licensed practical nurses (24%), medical or nursing assistants (27%), medical technicians (7%), physician assistants (4%), nurse practitioners (4%), and 1 pharmacist. Staff members were mostly white (97%) and women (98%). Overall, 76% of the patient-care staff participating at baseline were still in the practice at 18 months. The staff response rate to the 3 questionnaires was 96%.
Twenty-two prevention coordinators were hired. Five (23%) of the prevention coordinators were working in the practices and were hired for additional time, 6 were previously affiliated with the practice, and 11 were entirely new to the practice. Fifteen had nursing backgrounds, 4 were dietitians, and 3 were health educators.
The overall response rate to patient questionnaires was consistent with prestudy estimates of 50%. A total of 31,826 patients received an initial mailing consisting of a 9-item questionnaire and consent form. Fifty percent (n = 16,008) of the patients responded to this initial questionnaire mailing. Sixty-three percent (n = 10,158) of the responding patients were eligible, completed final questionnaires, consented, and had medical records reviewed. The resulting patient samples were predominantly women (56%), white (95%), married (77%), and had some college education (61%). The average age was 48 years. These figures were consistent across the 3 data collection points and are representative of census demographic data in the study regions. To address concerns about potential responder bias, we evaluated 4 practices in the same HMO by having them conduct an anonymous record review of a sample of eligible but nonconsenting patients. A comparison of the information from nonresponders’ records (n = 332) with the entire group of patients who were contacted indicated that nonresponders were less likely to have a documented cholesterol value, but no other significant differences related to study variables were found.
Intervention Outcomes
Goal setting. At the conference and during consultations, the practices were encouraged to follow a quality improvement process of first assessing current prevention services, then establishing goals for improvement. Physician and staff questionnaires and phone interviews revealed that nearly all practices (93%) reported setting goals to improve preventive services table 3. Practices in both the combined intervention and consultation groups set an average of 7 goals, while prevention coordinator practices averaged 5 goals, and conference-only practices averaged less than 3. The majority of the goals were related to implementing medical record tools, such as patient questionnaires, problem lists, flow sheet, or chart labels, or to increasing screening by making smoking a vital sign or routinely checking cholesterol levels. Risk factor management goals were set less often.
Practicewide meetings were recommended to develop consensus on prevention goals. On 12-month questionnaires, combined intervention practices reported a mean of 4 prevention meetings in the previous year, compared with 5 for prevention coordinator practices, 3 for consultation practices, and 1 meeting for conference-only practices.
Implementation of practice goals. To determine if practices followed through on their goals to use cardiovascular disease prevention record tools, we assessed the presence of cardiovascular disease risk information (a cholesterol level, hypertension diagnosis, or smoking status) on recommended tools in the medical record of each physician table 4 at baseline, 12, and 18 months, controlling for the baseline variables. Increases in cardiovascular disease risk documentation on the patient questionnaire (24%), problem list (35%), and medical record label (21%) were greatest in the combined intervention group at 12 months and were maintained at similar levels at 18 months. The prevention coordinator group showed the second-largest increases in use of the patient questionnaire (22%), problem list (13%), and chart label (10%) and had the largest increase in flow sheet use (22%), with most changes maintained at 18 months. Use of patient questionnaires, problem lists, and flow sheets increased to a lesser degree in the consultation group at 12 and 18 months. The conference-only group demonstrated a small increase in the use of patient questionnaires and flow sheets, used no chart labels, and did not improve their use of the problem list.
Changes in documentation of screening and management. Practices were encouraged to have a routine approach to screening, including a designated, easily accessible medical record location for risk factor documentation. For smoking screening, the problem list or a medical record label was defined as a recommended location, while the recommended location for hypercholesterolemia was the problem list, a medical record label, or a flow sheet. The percentage of all patients who had cardiovascular disease risk documented in a recommended location more than tripled in the combined intervention group, and this change was maintained at a significant level at 18 months. Screening documentation for at-risk patients in the prevention coordinator group significantly increased at 12 months and decreased slightly at 18 months. The consultation group increased screening rates, but these increases did reach significance table 5. There were no changes in the conference-only group.