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Use of a comprehensive QI program in primary care can improve delivery of preventive services for heart disease and stroke

A quality improvement (QI) program in which primary care practices hosted quarterly site visits, participated in two QI network meetings, and received copies of practice guidelines and quarterly performance reports improved the proportion of practice patients whose LDL cholesterol and blood pressure were controlled. In a study led by Steven Ornstein, M.D., of the Medical University of South Carolina, researchers examined the impact of the QI program for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke.

The study, which was supported by the Agency for Healthcare Research and Quality (HS11132), involved 20 community-based family and general internal medicine practices in 14 States, all of which used the same electronic medical record. Control practices received only the guidelines and performance reports. QI practices improved 22.4 percentage points (from 11.3 to 33.7 percent) in the percentage of indicators at or above the target compared with the 16.4 percentage points of control practices (from 6.3 to 22.7 percent), a nonsignificant difference. However, patients with hypertension in the QI practices had a 15.7 percentage point greater improvement in diagnoses of hypertension and an 8 percentage point greater improvement in blood pressure control than those in control practices.

On the basis of published estimates of the effect of blood pressure lowering, these improvements, if maintained for 10 years, might prevent 302 cardiovascular disease events (such as stroke and heart attack) and 209 deaths in the QI group and 224 cardiovascular disease events and 154 deaths in the control group. Clinicians cited use of multiple-agent hypertensive therapy, recommended in recent practice guidelines, as an explanation for better blood pressure control. The authors caution that the study involved only a small number of practices, limiting their ability to detect between-group differences, and it lacked a pure control group.

Details are in "A multimethod quality improvement intervention to improve preventive cardiovascular care," by Dr. Ornstein, Ruth G. Jenkins, M.S., Paul J. Nietert, Ph.D, and others, in the October 2004 Annals of Internal Medicine 141, pp. 523-532.

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