Communication Strategies for Primary Care Quality Improvement

(RCF: PCCE Trial)

Overseen By Ilana Brody

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: University of California, Los Angeles

Disqualifiers: Pediatrics, Urgent care, Design participants

Compensation: Varies

Number of Visits: Unknown

330 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests various methods of communicating performance feedback to primary care doctors at UCLA Health. The goal is to determine which method most effectively enhances doctors' quality of care. Three groups participate: one receives standard communication emails, another receives personalized performance report card emails, and the last receives personalized reports with feedback on how doctors' input shaped the program (bottom-up framing). Doctors in UCLA's primary care network with at least 50 patients are well-suited for this trial. As an unphased trial, this study provides an opportunity to contribute to the improvement of healthcare communication strategies.

Will I have to stop taking my current medications?

The trial does not specify whether participants must stop taking their current medications.

What prior data suggests that these communication strategies are safe for improving primary care quality?

Research has shown that personalized report cards as feedback tools in healthcare can improve patient care and strengthen doctor-patient relationships. These report cards provide individual performance information, helping to track and enhance care quality without safety concerns.

Studies also indicate that involving healthcare staff in creating and implementing quality improvement efforts leads to better patient outcomes. This approach ensures that safety and quality improvements are guided by those directly involved in patient care. Like personalized report cards, this method focuses on improving processes rather than introducing new medical treatments or medications, avoiding typical safety risks.

Overall, both personalized report card emails and staff involvement in quality improvements aim to enhance healthcare delivery rather than physical treatments, posing no safety risks for participants. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about this trial because it explores innovative communication strategies to enhance primary care quality improvement. Unlike standard communication methods, the personalized report card approach gives physicians individualized performance metrics, helping them understand their specific progress and areas for improvement. Additionally, the bottom-up framing technique uniquely incorporates physician feedback into program features, fostering a more collaborative and responsive healthcare environment. These approaches aim to empower physicians with better insights and engagement, potentially leading to improved patient care outcomes.

What evidence suggests that this trial's communication strategies could be effective for improving primary care quality?

This trial will compare different communication strategies to improve primary care quality. Arm 3, known as Personalized Report Card + Bottom-Up Framing, involves healthcare professionals directly in enhancing healthcare by actively engaging them in making improvements, which enhances teamwork and results. Arm 2, Personalized Report Card, provides healthcare providers with personalized report cards, offering feedback on their performance to improve communication, ensure patients follow their treatment plans, and increase overall patient satisfaction. Both the bottom-up approach and personalized report cards aim to enhance care by providing useful and relevant information to healthcare professionals. ^{6 7 8 9 10}

Who Is on the Research Team?

Richard Leuchter, MD

Principal Investigator

UCLA Health

Are You a Good Fit for This Trial?

This trial is for primary care physicians within the UCLA Health Department of Medicine Primary Care Network who are part of the PCCE Incentive program, have a clinical full-time employee level (FTE) of ≥ 40%, and manage a patient panel size greater than 50. Pediatric and Urgent Care physicians or those involved in designing this experiment are excluded.

Inclusion Criteria

Physicians with panel size >50 patients as of October 1, 2023

Primary care physicians within the UCLA Health Department of Medicine Primary Care Network that are eligible for the PCCE Incentive program as of October 1, 2023.

Physicians with the clinical full-time employee level (FTE) of ≥ 40% as of October 1, 2023

Exclusion Criteria

Physicians classified as Pediatrics will be excluded from data analysis given the structural differences in health maintenance guidelines for children.

Physicians who participate in the design of this experiment will be excluded from analysis.

Physicians classified as Urgent Care will be excluded from data analysis given the structural differences in their performance evaluation. They are all in Arm 1.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Intervention

Implementation of a three-arm experimental communication campaign with quarterly emails and surveys to improve physician performance and attitudes.

12 months

Quarterly emails and surveys

Follow-up

Participants are monitored for changes in physician behavior and attitudes, including engagement with resources and workplace attitudes.

12 months

What Are the Treatments Tested in This Trial?

Interventions

• Bottom-Up Framing
• Personalized Report Card Email
• Standard Communication Email

Trial Overview The study tests different methods to communicate quality improvement information to doctors: Personalized Report Card Email, Bottom-Up Framing, versus Standard Communication Email. The goal is to see which method better motivates physicians towards high-quality primary care delivery.

How Is the Trial Designed?

Group I: Arm 3: Personalized Report Card + Bottom-Up Framing Experimental Treatment 2 Interventions

Quarterly email communication as in Arm 2. Bottom-up intervention: The quarterly email communication will also describe the ways in which the PCCE program and its features were informed by physician feedback and recommendations. Quarterly survey: The quarterly survey will include information about the ways in which the PCCE program and its features were informed by physician feedback and recommendations. Physicians will respond to the same questions about physician attitudes and beliefs as in Arms 1 and 2.

Group II: Arm 2: Personalized Report Card Experimental Treatment 1 Intervention

Quarterly email communication: Quarterly personalized communication via email providing individualized performance metrics to physicians for the PCCE program from the prior quarter. All the links in the Arm 1 emails will be included in Arm 2 emails. Starting with the email communication in February 2024, there will be a reminder email sent two weeks after the first email with the same content. Quarterly survey: Quarterly standard communication via survey with the same questions about physician attitudes and beliefs as in Arm 1.

Group III: Arm 1: Standard Communication Arm Placebo Group 1 Intervention

Quarterly email communication: Quarterly standard communication via email providing a link to physicians to check their PCCE program performance over the prior quarter, and a link to access the PCCE dashboard. The email will also include a link to resources. Starting with the email communication in February 2024, there will be a reminder email sent two weeks after the first email with the same content. Quarterly survey: Quarterly standard communication via survey with questions about physician attitudes and beliefs.

Who Is Running the Clinical Trial?

University of California, Los Angeles

Lead Sponsor

Trials

1,594

Recruited

10,430,000+

Published Research Related to This Trial

The pharmacist-led SMASH intervention significantly reduced potentially hazardous prescribing rates by 40.7% after 12 months in 43 general practices serving over 235,000 people, demonstrating its efficacy in improving medication safety.

While the intervention also led to a 22.0% reduction in inadequate blood-test monitoring at 24 weeks, this improvement was not sustained at 12 months, indicating a need for ongoing monitoring in this area.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Evaluation of a pharmacist-led actionable audit and feedback intervention for improving medication safety in UK primary care: An interrupted time series analysis. Peek, N., Gude, WT., Keers, RN., et al.[2023]

Implementing quality improvement strategies in primary care can enhance the quality of patient-centered care and increase provider satisfaction.

The article provides key principles for effectively implementing these strategies, based on the authors' extensive experience in leading quality improvement efforts.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Quality Improvement Principles and Practice. Ratner, S., Pignone, M.[2020]

The Primary Care Practice Improvement Tool (PC-PIT) was found to be a valid and usable tool for enhancing quality improvement in general practices, as assessed by 28 staff members across six practices in Queensland, Australia.

Feedback indicated that the PC-PIT needs adjustments for better readability and simplification of complex terms, which will inform the development of additional resources to support its implementation in primary health care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Development and pilot study of the Primary Care Practice Improvement Tool (PC-PIT): an innovative approach. Crossland, L., Janamian, T., Sheehan, M., et al.[2019]

A survey of 226 Canadian family physicians revealed that while 55% had observed vaccine-associated adverse events (VAAEs), only 42% reported them, indicating a gap in reporting practices.

Less than 50% of physicians were aware of VAAE monitoring systems, and only 39% received education on VAAE during their training, highlighting the need for improved education and resources to enhance reporting of these events.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Reporting vaccine-associated adverse events. Duclos, P., Hockin, J., Pless, R., et al.[2018]

A new reporting tool for Adverse Drug Events (ADEs) and Medication Errors (MEs) was developed and pilot tested in 24 primary care practices, resulting in 507 reports over 10 weeks, demonstrating its effectiveness in busy clinical settings.

Clinicians found the tool user-friendly, with an average reporting time of under 2 minutes, which contributed to improved reporting rates of ADEs and MEs compared to existing systems.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

An adverse drug event and medication error reporting system for ambulatory care (MEADERS). Zafar, A., Hickner, J., Pace, W., et al.[2018]

A study involving 1095 patients and 60 general practitioners found that providing a booklet to patients significantly increased the reporting of adverse drug events (ADEs) related to antihypertensive medications, with patients in the intervention group being 3.5 times more likely to report ADEs compared to the control group.

The booklet not only enhanced ADE reporting but also improved patient satisfaction regarding communication with their general practitioners and management of high blood pressure, suggesting it could be a valuable tool in primary care settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Improving patient self-reporting of antihypertensive adverse drug events in primary care: a stepped wedge cluster randomised trial. Buchet-Poyau, K., Occelli, P., Touzet, S., et al.[2021]

The study involved 267 adult patients who received electronic medication safety messages, resulting in a high engagement rate where 79% opened the messages and 12% responded, often identifying medication-related issues.

The communication facilitated by the MedCheck application led to timely responses from clinicians, with 68% responding to patient messages, which helped in identifying and addressing 21 adverse drug events (ADEs), demonstrating the potential of electronic messaging to enhance medication safety.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Medication safety messages for patients via the web portal: the MedCheck intervention. Weingart, SN., Hamrick, HE., Tutkus, S., et al.[2018]

The integration of Alert Notification of Critical Results (ANCR) with electronic health records (EHR) allowed primary care providers (PCPs) to acknowledge nonurgent, clinically significant alerts effectively, with 100% acknowledgment of alerts expected from ANCR functionality.

Despite the new integration, the rates of follow-up for actionable alerts remained consistent before and after the intervention, indicating that while the workflow was enhanced, it did not significantly change the effectiveness of closed-loop communication regarding patient care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Does integrating nonurgent, clinically significant radiology alerts within the electronic health record impact closed-loop communication and follow-up? O'Connor, SD., Dalal, AK., Sahni, VA., et al.[2018]

A survey of patients identified seven key qualities that influence their satisfaction with primary care, including access, communication, provider demeanor, quality of medical care, care continuity, healthcare facilities, and office staff.

Communication and care coordination were particularly important, as deficiencies in these areas were strongly associated with lower patient satisfaction ratings, highlighting their critical role in patient experiences.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

What patients want: A content analysis of key qualities that influence patient satisfaction. Anderson, R., Barbara, A., Feldman, S.[2022]

The study found that nearly 90% of physician practices collect or use clinician performance information, and this practice is linked to higher patient experience scores in primary care settings.

Specifically, practices that shared performance information internally for comparison showed better patient experiences, suggesting that using this data effectively can enhance care quality and motivate clinicians.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Association between use of clinician performance information and patient experience. Zhou, RA., McIntosh, N., Rajan, R., et al.[2023]

General practitioners (GPs) found the Primary Care Practice Report (PCPR) to have poor usability, citing issues like unclear definitions, outdated data, and insufficient guidance for assessing clinical performance, which hindered their motivation to change practices.

The study suggests that for audit and feedback (A&F) strategies like the PCPR to be effective, they need to be designed with input from GPs to ensure they are clinically meaningful and user-friendly, as GPs indicated that well-designed feedback could enhance their motivation to improve clinical performance.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

'Give me something meaningful': GPs perspectives on how to improve an audit and feedback report provided by health insurers - an exploratory qualitative study. de Bekker, PJGM., de Weerdt, V., Vink, MDH., et al.[2022]

A systematic review of 52 studies on electronic patient records (EPRs) revealed that while prescribing data is generally of higher quality, there is significant variability in how data quality is measured, making comparisons across studies challenging.

The review highlighted the need for standardized methods in assessing EPR data quality, as many studies used different criteria, which complicates the interpretation of results and emphasizes the importance of clear definitions for terms like 'accuracy.'

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Systematic review of scope and quality of electronic patient record data in primary care. Thiru, K., Hassey, A., Sullivan, F.[2022]

A study involving 23 general practices and 1,818 asthmatic patients found that providing feedback about patients' asthma control to primary care teams did not result in significant improvements in patient outcomes, such as symptom frequency or medication use.

Despite high levels of reported asthma symptoms and low regular use of inhaled steroids among patients, the intervention did not lead to any measurable changes in breathlessness, health service use, or medication adherence compared to the control group.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Using information from asthma patients: a trial of information feedback in primary care. White, P., Atherton, A., Hewett, G., et al.[2019]

A survey of 3,565 primary care health professionals in Spain revealed that 39% responded, highlighting a significant gap in internal communication, particularly regarding awareness of projects and information dissemination, with doctors valuing communication more than other roles.

Many professionals (55%) do not use the intranet due to time constraints and difficulty, indicating a need for improved user-friendly communication tools and training in new technologies to enhance overall communication effectiveness.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[State of internal communication in primary care]. Ballvé Moreno, JL., Pujol Ribó, G., Romaguera Lliso, A., et al.[2021]

In a study of 304 adult consumers in Los Angeles, 66% preferred physicians with higher technical quality over interpersonal quality when choosing a primary care provider, indicating a strong preference for technical expertise.

Despite the preference for technical quality, many participants also valued interpersonal quality, suggesting that health care report cards should provide comprehensive information on both aspects to meet patient needs.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Patients' preferences for technical versus interpersonal quality when selecting a primary care physician. Fung, CH., Elliott, MN., Hays, RD., et al.[2022]

Citations

1. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC8432859/

Improving health care from the bottom up: Factors for ... Combining teamwork training with continuous improvement initiatives may not only enhance process measures, but also improve quality outcomes, such as patient ...

2. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC11151708/

Engaging health care professionals in quality improvement The interplay between the two projects was enabled by the bottom-up approach to implementation, participation of QI specialists, and a clear focus on developing ...

3. qualitysafety.bmj.com qualitysafety.bmj.com/content/32/2/65

Top-down and bottom-up approaches to low-value care Using evidence from 'bottom up' approaches to reduce low-value care. Decades of research in implementation science has emphasised that developing intervention ...

4. onlinelibrary.wiley.com onlinelibrary.wiley.com/doi/full/10.1002/nop2.2232

A bottom‐up framework for nurses' protocol‐based care ... This study provides a bottom-up framework for nurses' PBC decision-making, developed through a rigorous methodological approach.

5. implementationscience.biomedcentral.com implementationscience.biomedcentral.com/articles/10.1186/s13012-021-01171-7

Implementability of healthcare interventions: an overview of ... The framework of implementability of healthcare interventions may be particularly helpful in guiding effectiveness-implementation hybrid designs ...

6. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC9535208/

Aligning work-as-imagined and work-as-done using FRAM on ... Results illustrate how quality and safety in nursing can be addressed bottom-up together with stakeholders. HOW THIS STUDY MIGHT AFFECT ...

7. implementationscience.biomedcentral.com implementationscience.biomedcentral.com/articles/10.1186/s13012-020-0979-y

Assessing fidelity to evidence-based quality improvement as ... This paper develops and assesses clinical participants' fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity ...

8. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC11984039/

Primary care physician engagement in health systems ... Within the primary care setting, the use of physician engagement ensures the best patient outcomes, quality and safety but also prevents ...

9. research.birmingham.ac.uk research.birmingham.ac.uk/files/10387479/Framing_quality_improvement_tools.pdf

Framing quality improvement tools and techniques in ... Quality improvement has been one such effort to achieve better patient outcomes, better system performance and better professional development (Batalden and ...

10. researchgate.net researchgate.net/publication/269180536_Empowering_Sustained_Patient_Safety_The_Benefits_of_Combining_Top-down_and_Bottom-up_Approaches

Empowering Sustained Patient Safety: The Benefits of ... Combining top-down and bottom-up processes best facilitated the implementation and spread of the TeamSTEPPS safety initiative.