Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.

PURPOSEWe investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing selfdirected (SD) practices with model information and resources, without facilitation. METHODSWe conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys. RESULTSAlthough measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.CONCLUSIONS Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture. INTRODUCTIONT o meet the challenges of a reformed health care system, primary care must adopt substantially new models such as the PatientCentered Medical Home (PCMH) and integrate their work within accountable care organizations. [1][2][3][4] The PCMH has emerged as a cornerstone of primary care redesign with its strong appeal of uniting 4 compelling areas of health care reform: (1) the well-demonstrated value of primary care based on 4 core attributes, [5][6] (2) proactive, population-based approaches to chronic care, (3) consumerism and patient-centered care, and (4) new health information technology. Much of the redesign effort has focused on implementing the Chronic Care Model,6,7 which has been associated with better health outcomes for patients with chronic conditions and, specifically, type 2 diabetes 8,9 ; however, data regarding adoption of this model's principles into primary care practices have been disappointing. 10,11 Primary care practices have few mechanisms for incorporating new programs, which can slow adoption of innovations and cause disruptions when innovations are finally implemented. [12][13][14][15][16] With the central importance of primary care in health care redesign models such as the PCMH and accountable care organizations, effective strategies for enhancing primary care practice improvement...

Objective: The goal of this study was to assess the effects of training primary care providers (PCPs) to use Motivational Interviewing (MI) when treating depressed patients on providers' MI performance and patients' expressions of interest in depression treatment ("change talk") and short-term treatment adherence.Methods: This was a cluster randomized trial in urban primary care clinics (3 intervention, 4 control). We recruited 21 PCPs (10 intervention, 11 control) and 171 English-speaking patients with newly diagnosed depression (85 intervention, 86 control). MI training included a baseline and up to 2 refresher classroom trainings, along with feedback on audiotaped patient encounters. We report summary measures of technical (rate of MI-consistent statements per 10 minutes during encounters) and relational (global rating of "MI Spirit") MI performance, the association between MI performance and number of MI trainings attended (0, 1, 2, or 3), and rates of patient change talk regarding depression treatments (physical activity, antidepressant medication). We report PCP use of physical activity recommendations and antidepressant prescriptions and patients' short-term physical activity level and prescription fill rates.Results: Use of MI-consistent statements was 26% higher for MI-trained versus control PCPs (P ‫؍‬ .005). PCPs attending all 3 MI trainings (n ‫؍‬ 6) had 38% higher use of MI-consistent statements (P < .001) and were over 5 times more likely to show beginning proficiency in MI Spirit (P ‫؍‬ .036) relative to control PCPs. Although PCPs' use of physical activity recommendations and antidepressant prescriptions was not significantly different by randomization arm, patients seen by MI-trained PCPs had more frequent change talk (P ‫؍‬ .001). Patients of MI-trained PCPs also expressed change talk about physical activity 3 times more frequently (P ‫؍‬ .01) and reported more physical activity (3.05 vs 1.84 days in the week after the visit; P ‫؍‬ .007) than their counterparts visiting untrained PCPs. Change talk about antidepressant medication and fill rates were similar by randomization arm (P > .05 for both). Funding: Funding for this study was provided by the National Institute of Mental Health grant nos. K23MH0829972 and 3K23082997-S1; National Institutes of Health/National Center for Advancing Translational Sciences Colorado CTSI grant no. KL2 TR000156 (to CE).Conflict of interest: none declared. In this study we investigated whether a multifaceted MI training improved (1) PCPs' MI performance during index visits with patients with newly diagnosed depression; (2) subsequent outcomes related to patients' expressed interest ("change talk") in improving this condition; and (3) short-term adherence to treatment 5 (Figure 1). Depression is projected to become the leading cause of disability worldwide by 2030 6 and is often treated, at least in part, in primary care. 7,8 In general, poor depression outcomes in primary care 9 -11 are in part because of pervasive nonadherence to depression treatment, which is ...