Systematic Review of the Effectiveness of Practice Facilitation in Primary Care Settings to Improve Chronic Disease Outcomes Andrew Wang1,2,3,4, Megan Colleen McHugh1,2,4,6, Neil Jordan1,2,5,6, Abel N Kho3,4,5,6 1Center for Education in Health Sciences, 2Center for Healthcare Studies, 3Center for Health Information Partnerships, 4Emergency Medicine, 5Preventive Medicine, 6Institute for Public Health and Medicine Background Figure I. Conceptual Framework – Donabedian Model Table 2. Quality Assessment of Studies Methods: Education, process changes - checklists, flowsheets, electronic medical records, national guidelines, and Chronic Care Model. Cancer Prevention: Screening for breast, cervical, and colorectal increased. Cardiovascular Prevention and Treatment: Screening for blood pressure, cholesterol, height, weight, diets, smoking, and nutrition increased while adherence to cardiovascular care decreased; control of hypertension, cholesterol, and prescriptions for cardiovascular management improved. Diabetes Prevention and Treatment: Screening for diet, HbA1c, blood pressure, cholesterol, and foot/eye exams increased; control of Hba1c, blood pressure, and cholesterol improved. Asthma Treatment: Adoption of asthma action plans, adherence to medications, and asthma severity improved. Chronic Kidney Disease Treatment: Measurement of chronic kidney disease, anemia diagnosis, GFR mean, and aspirin use increased; blood pressure, cholesterol, and HbA1c outcomes improved. Chronic Illness Treatment: Patient-reported outcomes decreased. Results 117 million people in the US suffered from a chronic disease in 2012 Practice facilitation adopted to address the Chronic Care Model and improve chronic disease outcomes. Practice facilitators have prior clinical experiences and are involved with the practice on a long term basis. Practice facilitation involves individuals or a team working with a primary care practice to implement process changes in administrative and clinical areas. They evaluate practice performance, collect data on chronic disease outcome measures, formulate internal quality improvement, and improve process flows. Quality assessment Quality № of studie s Study design Risk of bias Inconsiste ncy Indirectn ess Imprecisi on Other considerati ons Cancer - Prevention: RCT   9 randomiz ed trials serio us not serious not serious none ⨁⨁⨁◯  MODERA TE Cancer - Prevention 1 observati onal studies very serio us ⨁◯◯◯ VERY LOW Cardiovascular Disease - Prevention: RCT 7 ⨁⨁◯◯ LOW Cardiovascular Disease Prevention Diabetes - Prevention: RCT 4 Diabetes – Prevention Confounding -spurious effect, no effect Asthma - Treatment: RCT ⨁⨁⨁◯ MODERA TE Asthma - Treatment 3 Cardiovascular Disease - Treatment: RCT not serio us ⨁⨁⨁⨁ HIGH Cardiovascular Disease - Treatment Chronic Kidney Disease - Treatment 2 Diabetes - Treatment: RCT Diabetes - Treatment 5 Chronic Illness publication bias strongly suspected Structure Practice Facilitators Affect the Structure Outpatient Setting Clinic Primary Care Practice Clinic Staff Clinical, Management, Administrative Patients Process Practice Facilitation Affects the Process Organizational, Clinical, and Business Functions Quality Improvement Data Collection, Feedback, Practice Enhancement Research Translated into Practice Study Designs: Non-Randomized Study Randomized Controlled Trials Outcomes Practice Facilitation Results in Effects in Outcomes Chronic Diseases Asthma, cancer, cardiovascular disease, diabetes, chronic kidney disease, chronic illness Prevention and Treatment outcomes Figure 2. Flow Diagram of Search Figure 3. Risk of Bias Assessment Objectives Examine practice facilitation in the primary care setting and chronic diseases outcomes addressed. Evaluate the effect of practice facilitation on chronic disease outcomes and study qualities. Practice facilitation led to effective improvement of prevention outcomes of cancer; treatment outcomes of asthma, cardiovascular disease, and diabetes. Practice facilitation led to ineffective improvement of prevention outcomes of cardiovascular disease and diabetes; treatment outcomes of chronic kidney disease and chronic illness outcomes. Limitations: Self-awareness, financial incentive, sample sizes, demographics differences, varying time commitments, exclusion of a meta-analysis. Discussion Methods Systematic review with a framework from PRISMA and the National Academy’s Standard for Systematic Reviews. Studies from North America (US and Canada), in the English language during1964 to 2016. Key Words: Improvement, practice coach, enhancement assistant, practice facilitator. Quality Assessment Tools: Cochrane’s Handbook for Systematic Reviews and GRADE Tool Ward, B.W., Schiller, J.S., & Goodman, R.A. (2014). Multiple chronic conditions among US adults: a 2012 update. Preventing Chronic Disease, 11, 130389. Wagner, E.H. (1998). Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice, 1(1):2-4.  Agency for Healthcare Research and Quality. (2013). Practice Facilitation Handbook. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/index.html. Donabedian, A. (1982). The Criteria and Standards of Quality. Explorations in Quality Assessment and Monitoring. Ann Arbor, Michigan: Health Administration Press. References Data Sources Study designs: Cohort and prospective studies, randomized controlled trials, and retrospective studies. Databases: Pubmed, Embase, and Web of Science Acknowledgements: This project was supported in part while the primary author was a National Research Service Award pre-doctoral fellow at the Center for Education in Health Sciences under an institutional award from the Agency for Healthcare Research and Quality, T-32 HS 000078 T32HS000084 (PI: Jane L Holl, MD, MPH). Assistance provided by Northwestern Librarians Corinne Miller and Jonna Peterson.