BACKGROUND: The Health Education and Research Trial (HEART) was a multicenter clinical trial designed to test methods to improve primary care practice systems for heart disease prevention services. We present the trial methodology, the practices’ use of medical record tools, and changes in documentation of cardiovascular risk factor screening and management.
METHODS: Primary care practices were recruited from 4 Midwestern states. The factorial design resulted in 4 study groups: conference only, conference and quality improvement consultations, conference and prevention coordinator, and all interventions combined. Medical record audits and physician, staff, and patient surveys assessed practice change in cardiovascular disease risk factor documentation.
RESULTS: Practices participated fully in this project, set goals to improve preventive services, and implemented recommended medical record tools. The number of goals set and the increase in the use of medical record tools were greatest in the combined intervention group, with improvements noted in all groups. The use of patient history questionnaires, problem lists, and flow sheets was significantly higher in the combined intervention group when compared with the conference-only group. Documentation of risk factor screening in a recommended medical record location improved in all intervention groups, with significant sustained improvements in the practices that received the combined intervention. Documented risk factor management significantly improved in all intervention groups compared with the conference-only control.
CONCLUSIONS: Primary care practices are interested in improving prevention systems and can change these systems in response to supportive external interventions. Promoting organizational change to produce sustained improvement in preventive service clinical outcomes is a complex process that requires further research.
Improving cardiovascular disease prevention services in primary care is increasingly recognized as a high priority, but self-reports, practice evaluations, and patient surveys indicate that physicians are not adequately identifying or treating people with cardiovascular disease risk factors.1-8 Organizational interventions and feedback systems can increase the delivery of preventive services.7,9-13 Several studies suggest that improving provider performance requires the interaction of personal factors, such as knowledge, attitudes, or training, and environmental factors, such as staff assistance, colleague support, referral resources, and office systems.7-10,14-16 Previous studies on improving cardiovascular disease preventive services had limited generalizability, because they studied academic or single practices, addressed a single risk factor, or evaluated only physician self-reports.7
The Health Education and Research Trial (HEART) used a factorial design to test 2 interventions to improve cardiovascular disease prevention services for adult patients in community primary care practices.17 Following an initial conference offered to all participating practices, the interventions were either a series of practice quality improvement consultations or the provision of a staff member called a prevention coordinator to assist with practice organization and patient education. The consultations involved relationship building, assessment, goal setting, intervention, and evaluation, similar to the quality improvement approaches currently used in managed care.18,19 The prevention coordinator intervention was developed on the basis of studies showing that staff can assist in the organization and provision of preventive services.14,19 It was hypothesized that either intervention alone would improve prevention practices but that the greatest effect would result from combining them, because they used complementary organizational strategies. Our initial report focuses on the outcomes of practice goal setting for preventive services and documentation of cardiovascular disease risk factor screening and management in private primary care practices.
Methods
Study Population
Primary care practices were recruited from a 100-mile radius of each of 4 regional centers: Madison and Eau Claire, Wisconsin; Minneapolis, Minnesota ; and Iowa City, Iowa. Forty-five practices were recruited sequentially during a 2-year period (1992-1994). We have previously described the recruitment protocols and outcomes.17
Interested physicians in practices meeting the criteria were required to consent to the following study activities: physician and staff attendance at a regional conference; provider completion of a series of 3 questionnaires; 3 random samplings and patient surveys; permission for 3 medical record audits of consenting patients’ charts; participation, if assigned, in the consultative process with their support staff; and acceptance, if assigned, of a prevention coordinator for 1 year. The exclusion criteria are provided in Table 1. Practices were compensated $250 per participating physician for completion of questionnaires and medical record handling.
Patient questionnaires and medical records provided information on physician and practice preventive services and were not used to assess patient outcomes. We took a sequential sample of equal numbers of men and women from appointment records with the goal of recruiting 35 patients per physician at baseline and 20 patients per physician at 12 and 18 months after the interventions began. The additional patients at baseline were used to obtain a risk cohort, which was not included in this report. The 3 patient samples were mutually exclusive; patients in earlier samples were excluded from any subsequent sample by reviewing patient logs. Eligible patients were aged 21 to 70 years; not pregnant; without a diagnosis of cancer, transplant, recent major surgery, or terminal illness; and had at least 2 practice visits in the past 2 years. Patients received a letter from their personal physician asking for their participation. The final sample included patients who consented within 4 weeks, completed baseline questionnaires, and were selected for a medical record review.