Laboratory reporting of estimated GFR coupled with an educational program markedly improves the recognition of CKD in the primary care setting.

ing prevention in primary care: evaluating the effectiveness of outreach facilitation. Family Practice 2008; 25: 40-48. Background. Out reach facilitation is designed to promote uptake of evidence-based guidelines. There is evidence indicating that outreach facilitation can be effective in improving implementation of preventive care in GPs' offices. In this trial, we test a modified version of an outreach facilitation intervention.Objective. To evaluate whether a comprehensive preventive intervention program using outreach facilitators improves preventive care delivery. Design. Match-paired, cluster-randomized controlled trial.Setting. Fee-for-service primary care practices in Eastern Ontario, Canada, at a time of physician shortage. Participants. Volunteer sample of 54 primary care practices.Main outcome measures. Mean difference between trial arms in practices' delivery of preventive manoeuvres, measured by preventive performance indices estimated from chart reviews and patient survey data. Results. No difference was detected between the trial's arms for the primary outcome's overall prevention index [2.0%; 95% confidence interval (CI) -3.2 to 7.3; P = 0.44]. A small significant difference between the arms was detected for the secondary outcome's overall prevention index (2.8%; 95% CI 0.7-4.8; P = 0.01). Conclusion. In contrast to similar facilitation trials, this outreach facilitation program did not produce improvements in the delivery of preventive care. This lack of effect may be due to differences in the intervention and context, or the practice's limited capacity to change. Our intervention simultaneously facilitated a high number of manoeuvres, blinded facilitators and physicians to the targeted tests and had a relatively short intervention period and large number of practices assigned per facilitator. Changes in the primary care service model in Ontario at the time of the trial could have also washed out the intervention effect.

BackgroundOutreach facilitation has been proven successful in improving the adoption of clinical preventive care guidelines in primary care practice. The net costs and savings of delivering such an intensive intervention need to be understood. We wanted to estimate the proportion of a facilitation intervention cost that is offset and the potential for savings by reducing inappropriate screening tests and increasing appropriate screening tests in 22 intervention primary care practices affecting a population of 90,283 patients.MethodsA cost-consequences analysis of one successful outreach facilitation intervention was done, taking into account the estimated cost savings to the health system of reducing five inappropriate tests and increasing seven appropriate tests. Multiple data sources were used to calculate costs and cost savings to the government. The cost of the intervention and costs of performing appropriate testing were calculated. Costs averted were calculated by multiplying the number of tests not performed as a result of the intervention. Further downstream cost savings were determined by calculating the direct costs associated with the number of false positive test follow-ups avoided. Treatment costs averted as a result of increasing appropriate testing were similarly calculated.ResultsThe total cost of the intervention over 12 months was $238,388 and the cost of increasing the delivery of appropriate care was $192,912 for a total cost of $431,300. The savings from reduction in inappropriate testing were $148,568 and from avoiding treatment costs as a result of appropriate testing were $455,464 for a total savings of $604,032. On a yearly basis the net cost saving to the government is $191,733 per year (2003 $Can) equating to $3,687 per physician or $63,911 per facilitator, an estimated return on intervention investment and delivery of appropriate preventive care of 40%.ConclusionOutreach facilitation is more expensive but more effective than other attempts to modify primary care practice and all of its costs can be offset through the reduction of inappropriate testing and increasing appropriate testing. Our calculations are based on conservative assumptions. The potential for savings is likely considerably higher.

Background: Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting.