Facilitating Practice Change in Primary Care: A Multi-faceted Intervention ACPNet Pilot Study

Abstract

Purpose: The purpose of this pilot study was to: 1) understand the attitudes, knowledge and beliefs of internists in managing patients with COPD, and 2) evaluate the impact of a multi-faceted approach to quality improvement work involving the management of COPD patients. Scope: COPD affects more than 5% of the adult population, is the fourth leading cause of death, and the twelfth leading cause of morbidity in the United States. Primary care physicians manage the majority of patients with COPD, yet there remains a scarcity of research into the quality of care these physicians are providing. Methods: This pilot study utilized a pre-post intervention design. Research staff sought to employ a multifaceted approach by providing physicians with quality improvement coaching via conference calls/email exchanges, utilizing physician feedback reports as starting points for their quality improvement work, and providing them with a web-based education tool kit which they could access at their convenience. Data was collected using a practice pattern survey and a chart abstraction tool to identify discrepancies between perceived and actual care at baseline and follow-up (six months post-baseline). These discrepancies and physician feedback reports were used as motivators of change for the practices. The survey, chart abstraction tool and web-based education toolkit were developed by experts in the field of pulmonology, primary care, and practice-based research. Results: Results from the pilot study showed a statistically significant improvement in quality indicators post-intervention, suggesting a causal relationship with the multi-faceted intervention. Specifically, statistically significant findings from patient chart audit data include improvements in: 1) FEV1, 2) oxygenation measurement, 3) pulse oximetry at rest, 4) alpha-1 antitrypsin measurement in patients 50 years of age and under, 5) recommendation of regular exercise, 6) inhaler use instruction, and 7) assessment of peak flow. Statistically significant survey data findings include the physicians' report of an increase in the number of nurses giving inhaler use instructions to patients. Discrepancies were identified between perceived and actual care including sprirometry, pulse oximetry (exertion and resting), influenza and pneumococcal vaccination rates, peak flow assessment, and inhaler use instruction. Key Words: practice-based research, quality improvement, COPD, evidence-based best practices.