Practice-Tailored Facilitation to Improve Pediatric Preventive Care Delivery: A Randomized Trial

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Children receive only half of recommended health care; disadvantaged children have higher risk of unmet needs. Practice coaching combined with quality improvement using rapid-cycle feedback has potential to help practices meet quality standards and improve pediatric health care delivery. WHAT THIS STUDY ADDS:The Practice-tailored Facilitation Intervention led to large and sustained improvements in preventive service delivery, including substantial numbers of disadvantaged children, and in multiple simultaneous health care domains. Practice-tailored facilitation holds promise as a method to advance pediatric preventive care delivery. abstract OBJECTIVE: Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services. METHODS:In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods. RESULTS:Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: ,0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P , .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P , .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need.CONCLUSIONS: Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.

Engaging Primary Care Practices in Studies of Improvement: Did You Budget Enough for Practice Recruitment?

“…17,21 In 2017 engagement and recruitment required relationship building at multiple levels, with health information technology staff, health system leaders, administrative staff, and practice staff involved in reporting quality measures and implementing tailored practice facilitation that aligns quality improvement initiatives with federal and local practice strategic goals. 12,22,23 The cost of recruiting practices without a existing partnership is expensive, costing 7 times more than engaging familiar practices. Supporting the infrastructure of organizations that have a sustained, trusted relationship with practices is needed in largescale practice improvement efforts.…”

Promoting Oral Health in Childhood: A Quality Improvement Project

“…In the first 4 months of the 6-month study period, FV application rates rose from a baseline of <1% to 89% in the practices randomly assigned to receive facilitation intervention versus 4.4% in the control group. 15 In our project, by incorporating a less-costly model by using a practice change champion with access to local improvement expertise, barriers to effective care were identified through process flow mapping, data were fed back to the clinical teams, and changes were implemented to drive improved outcomes. Although our FV application rates peaked at 86%, higher rates are feasible with sustained intervention.…”

The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review

“…All 28 included studies were cluster RCTs. Most RCTs were carried out in high-income countries, with 15 in the USA [40][41][42][43][44][45][46][47][48][49][50][51][52][53][54], two in the Netherlands [55,56], two in Canada [57,58], two in the UK [59,60], and one each in Sweden [61] and Spain [62]. Four RCTs were undertaken in the middle-or low-income countries, specifically in India [63], Mexico [64], Nigeria [65], and Malawi [66].…”