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Training in continuous quality improvement may not improve preventive services in primary care clinics

Coaching staff of primary care clinics to increase preventive services by using a continuous quality improvement (CQI) team does not substantially improve their delivery of preventive services over clinics that do not receive CQI training, according to a new study supported by the Agency for Healthcare Research and Quality (HS08091). Leif I. Solberg, M.D., of HealthPartners Research Foundation, Minneapolis, MN, and his colleagues randomly assigned 44 primary care clinics in the same area to CQI training or no training (controls). The CQI clinics received leadership support, training, consulting, and networking to help multidisciplinary teams at each clinic use CQI methods to develop and implement eight prevention services.

These services for adults 19 years and older (except when otherwise indicated) included a yearly blood pressure measurement, cholesterol measurement every 5 years, assessment of tobacco use and smoking cessation advice, Pap smear every 2 years, breast exam every 2 years, mammogram every 2 years for women older than 49, annual influenza shot for the elderly, and a one-time pneumovax shot for patients older than 64. The researchers asked the patients and reviewed their charts to see if they had received these services.

They found that patient reports of receiving needed cholesterol tests increased 5 percent more in CQI versus control clinics. Chart audits showed that blood pressure measurements increased 3.6 percent more in CQI than control clinics. Beyond these improvements, increases in delivery of prevention services were not significantly greater in CQI versus control clinics. There are several possible explanations for these results. Recruited clinics had unusually high rates for these services, causing a ceiling effect; the CQI program was inadequately delivered; the clinics were inexperienced in organizational change; and/or there was inadequate tension for change. The researchers believe the trial demonstrated the relative ineffectiveness of the particular CQI approach they tested.

More details are in "Failure of a trial of continuous quality improvement and systems intervention to increase the delivery of clinical preventive services," by Dr. Solberg, Thomas E. Kottke, M.D., Milo L. Brekke, Ph.D., and others, in the May/June 2000 Effective Clinical Practice 3, pp. 105-115, and a commentary, "Improving prevention is difficult," also in Effective Clinical Practice 3, pp. 153-155.

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