Practice based education to improve delivery systems for prevention in primary care: randomised trial

doi:10.1136/bmj.38009.706319.47

BMJ 2004;328:388 (14 February), doi:10.1136/bmj.38009.706319.47 (published 6 February 2004)

Primary care

Practice based education to improve delivery systems for prevention in primary care: randomised trial

Peter A Margolis, professor of pediatrics and epidemiology¹, Carole M Lannon, associate professor of pediatrics and internal medicine¹, Jayne M Stuart, assistant professor of pediatrics¹, Bruce J Fried, associate professor of health policy and administration², Lynette Keyes-Elstein, assistant director of biostatistics³, Donald E Moore, Jr, director, division of continuing medical education⁴

¹ University of North Carolina at Chapel Hill, North Carolina Center for Children's Healthcare Improvement, 730 Airport Rd, Ste 104, CB#7226, Chapel Hill, NC 27599, USA, ² University of North Carolina at Chapel Hill, School of Public Health, Department of Health Policy and Administration, Chapel Hill, ³ Rho Inc, Chapel Hill, NC 27514, USA, ⁴ Vanderbilt University School of Medicine, Nashville, TN 37232, USA

Correspondence to: P A Margolis Peter_Margolis{at}med.unc.edu

Objective To examine the effectiveness of an intervention thatcombined continuing medical education with process improvementmethods to implement "office systems" to improve the deliveryof preventive care to children.

Design Randomised trial in primary care practices.

Setting Private paediatric and family practices in two areasof North Carolina.

Participants Random sample of 44 practices allocated to interventionand control groups.

Intervention Practice based continuing medical education inwhich project staff coached practice staff in reviewing performanceand identifying, testing, and implementing new care processes(such as chart screening) to improve delivery of preventivecare.

Main outcome measure Change over time in the proportion of childrenaged 24-30 months who received age appropriate care for fourpreventive services (immunisations, and screening for tuberculosis,anaemia, and lead).

Results The proportion of children per practice with age appropriatedelivery of all four preventive services changed, after a oneyear period of implementation, from 7% to 34% in interventionpractices and from 9% to 10% in control practices. After adjustmentfor baseline differences in the groups, the change in the prevalenceof all four services between the beginning and the end of thestudy was 4.6-fold greater (95% confidence interval 1.6 to 13.2)in intervention practices. Thirty months after baseline, theproportion of children who were up to date with preventive serviceswas higher in intervention than in control practices; resultsfor screening for tuberculosis (54% v 32%), lead (68% v 30%),and anaemia (79% v 71%) were statistically significant (P <0.05).

Conclusion Continuing education combined with process improvementmethods is effective in increasing rates of delivery of preventivecare to children.

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