Safety-net institutions in the US grapple with new cholesterol treatment guidelines: a qualitative analysis from the PHoENIX Network

Valy Fontil,1,2 Courtney R Lyles,1,2 Dean Schillinger,1,2 Margaret A Handley,1–3 Sara Ackerman,4 Gato Gourley,1,2 Kirsten Bibbins-Domingo,1–3 Urmimala Sarkar1,2 1UCSF Center for Vulnerable Populations at San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA; 2Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; 3Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; 4Department of Social and Behavioral Sciences, University of California San Francisco School of Nursing, San Francisco, CA, USA Background: Clinical performance measures, such as for cholesterol control targets, have played an integral role in assessing the value of care and translating evidence into clinical practice. New guidelines often require development of corresponding performance metrics and systems changes that can be especially challenging in safety-net health care institutions. Understanding how public health care institutions respond to changing practice guidelines may be critical to informing how we adopt evolving evidence in clinical settings that care for the most vulnerable populations. Methods: We conducted six focus groups with representatives of California’s 21 public hospital systems to examine their reactions to the recent 2013 cholesterol treatment guideline. Results: Participants reported a sense of confusion and lack of direction in implementing the new guideline. They cited organizational and data infrastructural inadequacies that made implementation of the new guidelines impractical in their clinical settings. Conclusion: Adopting new performance measures to align with evolving cholesterol guidelines is a complex process that may work at odds with existing quality improvement priorities. Current efforts to translate evidence into practice may rely too much on performance measures and not enough on building capacity or support for innovative efforts to meet the goals of guidelines. Keywords: pay-for-performance, value-based payment, quality improvement