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Supplemental material, sj-docx-1-smo-10.1177_20503121211069855 for What strategies are used by clinician champions to reduce low-value care? by Michael L Parchman, Lorella G Palazzo, Jessica M Mogk, Janna C Webbon, Lauren Demosthenes, Elizabeth Vossenkemper, George Hoke, Joshua Moskovitz, Leslie Dunlap and Roberto Diaz del Carpio in SAGE Open Medicine

Aims and Objective: The validation study of the Patient Assessment of Chronic Illness Care (PACIC) questionnaire suggested a 5-factor structure determined a priori, but subsequent analyses have questioned the validity of the original factor structure. This study analyzed the factor structure of the PACIC using a large and diverse patient sample, and evaluated the identified factors through the lens of recent transformational initiatives in primary care.Convenience samples of adults completed surveys in waiting rooms during clinic visits. Primary care patients with 1 or more chronic illnesses with complete PACIC responses at baseline from 39 clinics (n=1,567) and at follow-up from 36 clinics (n=1,536) participated. Exploratory and confirmatory factor analyses were conducted on baseline and follow-up patient questionnaire data from a cluster randomized controlled trial. Identified factors were evaluated in terms of item loadings, content, reliability, and the extent to which items reflected advances in the delivery of chronic illness care.Analyses supported the use of the PACIC summary score. Although a 5-factor model was retained, factor loadings were different from the original PACIC validation study. All factors had sufficient reliability, but findings suggested potential revisions to enhance the factor structure.It may be time to revise the PACIC to enhance the stability of the subscales (factors) and better reflect recent transformations in the delivery of chronic illness care.

A recent systematic review suggests that practice facilitation (PF) is a robust intervention for implementing evidence-based preventive care guidelines in primary care, but the ability of PF to improve chronic illness care remains unclear.To examine the specific activities and Chronic Care model (CCM) components that primary care practices implemented and sustained in response to a 12-month PF intervention.The ABC trial tested the effectiveness of PF to improve care for diabetes in 40 small community-based primary care practices that were randomized to "initial" or "delayed" intervention arms. A trained facilitator met with each practice over 12-months. Facilitators used interactive consensus building to help practices implement one or more of quality improvement activities based on the CCM. Facilitators prospectively recorded implementation activities reported by practice teams during monthly meetings and confirmed which of these were sustained at the end of the intervention.37 practices implemented and sustained a total of 43 unique activities [range 1-15, average 6.5 (SD=2.9)]. The number (%) of practices that implemented 1 or more key activities in each CCM component varied: Patient Self-Management Support: 37 (100%); Clinical Information Systems: 24 (64.9%), Delivery System Design: 14 (37.8%), Decision Support: 13 (35.1%), Community Linkages: 2 (5.4%); Healthcare System Support: 2 (2.7%). The majority of practices (59%) only implemented activities from 1 or 2 CCM components. The number of sustained activities was associated with the number of PF visits, but not with practice characteristics.In spite of the PF intervention, it was difficult for these small practices to implement comprehensive CCM changes. Although practices implemented and sustained a remarkable number and variety of key activities, the majority of these focused on patient self-management support, as opposed to other components of the CCM, such as clinical information systems, decision support, delivery system redesign, and community linkages.

Implementing improvement programmes to enhance quality of care in primary care clinics is complex. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient centred medical homes (PCMH). This study examined practice members' perceptions of the opportunities and challenges associated with implementing changes in their practice.Semi-structured interviews were conducted with a sample of 56 individuals working in 16 small, community based primary care practices. The interviews consisted of open-ended questions focused on participants' perceptions of: (1) practice vision, (2) perceived need for practice improvement and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analysed.Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients' involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking and follow-up, standardisation of processes of care and overall clinic documentation. Changes related to patients' involvement in their care included improving (a) health education, and (b) self-care management. Among the internal barriers were: staff readiness for change, poor communication and relationship difficulties among team members. External barriers were insurance regulations, finances and patient health literacy.Transforming practices to more patient-centred models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programmes. Successful strategies for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members' perceived needs and planned improvement efforts.

To examine the common clinical and behavioural factors that contribute to cardiovascular disease (CVD) risk (ie, attributable risk) among those with type 2 diabetes.Analysis of data from a larger observational study. Using the validated UK Prospective Diabetes Study risk engine, the primary analysis examined the prevalence and attributable risk of CVD for 4 factors. Multivariable models also examined the association between attributable CVD risk and appropriate self-management behaviour.Twenty primary health care clinics in the South Texas area of the United States.A total of 313 patients with type 2 diabetes mellitus currently receiving primary care services for their condition.Prevalence of elevated CVD risk factors (glycated hemoglobin [HbA(1c)] levels, blood pressure, lipid levels, and smoking status), the attributable risk owing to these factors, and the association between attributable risk of CVD and diet, exercise, and medication adherence.The mean 10-year CVD risk for the study population (N = 313) was 16.2%, with a range of 6.5% to 48.5% across clinics; nearly one-third of this total risk was attributable to modifiable factors. The primary variable driving risk reduction was HbA(1c) levels, followed by smoking status and lipid levels. Patients who were carefully engaged in monitoring their diets and medications reduced their CVD risk by 44% and 39%, respectively (P.03).Patients with diabetes experience a substantial risk of CVD owing to potentially modifiable behavioural factors. High-quality diabetes care requires targeting modifiable patient factors strongly associated with CVD risk, including self-management behaviour such as diet and medication adherence, to better tailor clinical interventions and improve the health status of individuals with this chronic condition.