A continuing education programme designed to assist primary care practices in testing and implementing “office systems” for preventive health care produced clinically and statistically significant improvement in rates of preventive care for children. By combining information about effective approaches to preventive care, organised tools and resources, and training in modern methods of process improvement, practices could focus their efforts at improvement.
A growing body of literature indicates that continuing medical education based on the way care is delivered in the practice setting can affect the outcomes of care delivery.17
However, efforts to help practices implement office systems have produced mixed results. In a randomised trial, Dietrich et al found that in primary care practices that implemented office systems, the performance of mammography and clinical breast examinations improved significantly.18
Subsequent attempts to introduce office systems to improve preventive care for adults have been unsuccessful.19,20
Reasons for the limited impact of such interventions include the size and complexity of practices involved, staff turnover, using a suboptimal quality improvement model that placed too much emphasis on planning rather than testing changes, insufficient emphasis on measurement to determine if changes were resulting in improvement, lack of motivation to change, inadequately developed content materials, inexperienced improvement team leaders, and insufficient time for improvement activities.21
Using a formal practice assessment, a practice-wide meeting, and prevention tools, and giving feedback on performance every six months, Goodwin et al reported a small but statistically significant increase in rates of preventive services.22
We used a somewhat different approach, working side by side with the office team, providing information and coaching to each practice to develop improvement expertise within the practice. This avoided the loss of performance associated with “train the trainer” models23
because it did not depend on novice leaders during what was often their first application of improvement methods. We emphasised frequent, small scale tests to enable practices to “try out” changes without risking disruption of practice routines. The provision of tools and materials allowed practices to concentrate on improving care, and the emphasis on measurement encouraged practices to learn from their data, thereby engendering trust in the process.
This study has several limitations. We selected practices that provided care for relatively large numbers of children in order to be able to detect an intervention effect. Small paediatric practices and most family practices were excluded. Although this may limit the generalisability of the study to multi-physician settings, such environments tend to be more complex and thus stand to benefit more from quality improvement efforts.
The primary outcome measure was the proportion of children within each practice who received all four age appropriate services. Some clinicians may not have agreed that all procedures were necessary; some children may not have been exposed to practice changes; and some services may have been provided without being documented. The increased use of blood and skin testing, in addition to risk factor screening, implies that improvements did not represent improved documentation alone.
Immunisation rates did not improve significantly, but at the time the study was conducted North Carolina implemented a universal vaccine purchase programme. It became the state with the highest rates of immunisations in the United States.24
Although a multi-arm trial could have evaluated the incremental value of audit and feedback, this approach would have increased the logistical complexity of the study. The existing evidence indicated that this intervention would have small to moderate effectiveness when used alone.3
In addition to the measurable results obtained in this study, we were encouraged by intervention practices' response. Given information about performance and a variety of evidence based strategies and tools, practices were motivated to test alternative approaches to care. Several practice improvement teams went on to initiate change in other clinical areas, such as asthma. Our results are of potential importance to current efforts to incorporate performance improvement and systems thinking as a core competency for physicians and other health professionals.
This study shows that continuing education oriented to improving primary care practices' systems for delivery of care is associated with important improvements in preventive care. An important next step will be to reduce the costs of assistance and to disseminate new approaches to more practices more rapidly. Future studies should also explore how to further increase the reliability of care, magnify the rate of improvement, and sustain improvements.
What is already known on this topic
Most preventive services are recommended for children under 5 years of age, but rates for their delivery in primary care are lower than desired
Better “office systems” for preventive care seem to be associated with improved care, but efforts to help practices implement such systems have produced mixed results
Continuing medical education based on the way care is delivered in the practice setting can affect the outcomes of care delivery
What this study adds
Practice oriented continuing education, combined with process improvement methods, can improve systems for delivery of preventive care in primary care
Improvements in office systems are associated with important improvements in rates of preventive care