Practice Transformation Support and Patient Engagement to Improve Cardiovascular Care

From EvidenceNOW Southwest (ENSW)

W. Perry Dickinson, MD; Donald E. Nease, Jr., MD; Robert L. Rhyne, MD; Kyle E. Knierim, MD; Douglas H. Fernald, MA; Dionisia R. de la Cerda, MPA; L. Miriam Dickinson, PhD


J Am Board Fam Med. 2020;33(5):675-686. 

In This Article

Abstract and Introduction


Purpose: To improve cardiovascular care through supporting primary care practices' adoption of evidence-based guidelines.

Study Design: A cluster randomized trial compared two approaches: (1) standard practice support (practice facilitation, practice assessment with feedback, health information technology assistance, and collaborative learning sessions) and (2) standard support plus patient engagement support.

Methods: Primary outcomes were cardiovascular clinical quality measures (CQMs) collected at baseline, 9 months, and 15 months. Implementation of the first 6 "Building Blocks of High-Performing Primary Care" was assessed by practice facilitators at baseline and 3, 6, and 9 months. CQMs from practices not involved in the study served as an external comparison.

Results: A total of 211 practices completed baseline surveys. There were no differences by study arm (odds ratio [95% confidence interval]) for aspirin use (1.03 [0.99, 1.06]), blood pressure (0.98 [0.95, 1.01]), cholesterol (0.96 [0.92, 1.00]), and smoking (1.01 [0.96, 1.07]); however, there were significant improvements over time in aspirin use (1.04 [1.01, 1.07]), cholesterol (1.05 [1.03, 1.08]), and smoking (1.03 [1.01, 1.06]), but not blood pressure (1.01 [0.998, 1.03]). Improvement in enrolled practices was greater than external comparison practices across all 4 measures (all P < .05). Implementation improved in both arms for Team-Based Care, Patient-Team Partnership, and Population Management, and improvement was greater in enhanced intervention practices (all P < .05). Leadership and Data-Driven Improvement (P < .05) improved significantly, with no difference by arm. A greater improvement in Building Block implementation was associated with a greater improvement in blood pressure measures (P < .05).

Conclusions: Practice transformation support can assist practices with improving quality of care. Patient engagement in practice transformation can further enhance practices' implementation of aspects of new models of care.


Cardiovascular disease (CVD) causes 1 in 3 deaths reported each year in the United States, with heart disease the first and stroke the fifth leading cause of death.[1–3] Addressing CVD risk factors can greatly reduce the burden of CVD. Primary care practices must transform to deliver a higher level of evidence-based prevention to decrease cardiovascular risk. Interventions that emphasize patient-centered care have been shown to be effective.[4–11] Practices often require assistance integrating new practice approaches into clinical operations. Practice facilitation can enhance implementation of new programs for patients with chronic disease.[12–16] Other methods of practice support, including academic detailing, collaborative learning sessions, and health information technology (HIT) assistance, have also been shown to be effective.[12,17–28]

Practices are increasingly including patients as part of practice transformation through the creation of patient and family advisory councils and participation in quality improvement teams.[29–33] The boot camp translation method can inform implementation of evidence-based care through engaging patients, clinicians, and staff members to translate best practices into culturally and community-relevant messages and materials for patient engagement.[26,34–38] Although patient engagement through patient and family advisory councils has been encouraged as part of practice transformation, no study to date has compared the impact of adding patient engagement methods to more standard practice transformation methods.

EvidenceNOW Southwest (ENSW), a collaborative effort between Colorado and New Mexico, is 1 of 7 regional cooperatives funded by the Agency for Health care Research and Quality to help small-and medium-sized primary care practices improve cardiovascular care while also improving practice capacity for quality improvement. The conceptual model for the practice transformation support design, adapted and modified from previous models,[39,40] can be found in Figure 1. Based on this model, we developed 2 practice transformation support interventions: (1) "standard" practice transformation support, including practice facilitation, HIT assistance, and collaborative learning sessions; and (2) an "enhanced" approach that added support for patient engagement (including patient and family advisory councils and patient engagement materials tailored for specific populations through boot camp translation) to the standard intervention. We hypothesized that both intervention arms would demonstrate improvement in cardiovascular risk outcomes, that the addition of patient engagement activities would result in a greater improvement for the enhanced intervention, and that both approaches would result in greater improvements compared with an external comparison group receiving no support. The "Bodenheimer Building Blocks for High-Performing Primary Care"[41] were used as a framework for guiding practice improvement and were hypothesized as key intermediate outcomes and mediators of the practice transformation interventions.

Figure 1.

Conceptual model for EvidenceNOW Southwest intervention.