Practices were encouraged to improve cardiovascular disease risk factor management by providing and documenting smoking cessation advice, quit dates, or nicotine replacement for smokers and diet advice or medication for patients with elevated cholesterol levels. When medical records of patients with risk factors (smoking, cholesterol >200 mg/dL, or hypertension) were reviewed, baseline values indicate that appropriate management of cardiovascular disease risk was documented for approximately 65% of the patients. Significant increases in risk management documentation were noted for the combined intervention group at 12 months compared with the conference-only group. Increases in other groups were not significant. However, at 18 months, all intervention groups had increased documentation of risk management compared with the control, with a significant difference in the prevention coordinator and consultation groups table 5.
Discussion
This study demonstrates that physicians, staff, and their practices will participate in health services research and make efforts to improve preventive services. More than 60% of the eligible practices contacted consented to participate in our trial.17 Practices were willing to evaluate their current preventive services, set goals, and develop improvement strategies. Practice members were receptive to the innovative conference and consultation formats and were especially positive about including all office staff. Many practices reported that the HEART conference was the first time they had ever met as an entire staff for any reason. Although there was initial resistance to the time involved in practicewide meetings, the vast majority of practices participated fully and were positive about their participation.
Our study also shows that practices can set goals, make changes in practice organization for prevention services, and increase risk factor screening and management documentation. Practice process change requires significant effort and is difficult to initiate without consensus and group support.10,14,20,21 Many physicians reported that before this study they had inadequate training or time for development and implementation of system changes and quality improvement. Physicians acknowledged that staff involvement is critical for office system change, and staff were enthusiastic about an expanded role in the prevention process. The greater number of practice meetings in the combined intervention group may have resulted in the larger preventive system changes. Group meetings facilitate communication and consensus development, which are important parts of organizational change.10,22,23
Medical records are appropriately viewed as tools to assist in optimal patient care. Practices were receptive to medical record changes that were designed to efficiently improve preventive care. Before this study, many practices were not routinely using problem lists, patient questionnaires, and flow sheets. Consultant faculty emphasized the benefits of these tools for organizing a prevention system, and as a result, combined intervention and prevention coordinator practices were more likely to use these tools for risk factor screening and management. Other studies support the need to make changes in practice systems to increase preventive services.11 In a randomized controlled trial in a staff model HMO, physician training and office systems changes increased physician counseling rates and resulted in significant decreases in patient cholesterol levels and body weight. The use of physician training alone did not produce an increase in counseling or change in patient outcomes, indicating that training is not adequate, and systems changes are needed to create a supportive office environment that will improve services.11
The study design allowed practices to set their own goals and timetable for change, as is recommended for quality improvement plans, and the resulting changes varied among the practices. The practices set screening goals more often than management goals, and smoking screening goals were set most often. This may have been due to physician and practice attitudes, exposure to previous practice guidelines, or because smoking screening requires fewer steps to accomplish than cholesterol screening. Screening goals may have been more common because screening is the first step in the prevention process. Screening, in general, is less complex than the provider and patient behavior change required for management services, and therefore, screening goals may be easier to achieve. Screening provides the foundation for management services, and our study results show that the combined intervention, consultation, and prevention coordinator practices achieved significant improvements not only in their documentation of screening but also in documenting management for patients with cardiovascular disease risk factors.
We noted differences in the effects of the consultation and prevention coordinator interventions. Consultation practices set more goals, but prevention coordinator practices achieved greater increases in the use of medical record tools and in the documentation of screening and management. The communication and collaboration involved in the consultations seemed to lead to more meetings and goal setting, while the additional dedicated prevention coordinator time appeared to improve implementation of the goals. Regarding documentation of cardiovascular disease screening after the 12-month intervention period, our 18-month results show screening rates continued to increase in the consultation group, but screening rates decreased in the prevention coordinator group. These results may indicate that the time and possibly leadership of the prevention coordinator was necessary to maintain changes in screening routines. The consultations produced smaller changes in screening during the intervention, but those changes seemed to be more durable.