Practice improvement and quality improvement are both terms used to describe the systematic approach of assessing practice performance and making changes to standardize and improve care.7,8 Often these terms are used interchangeably; however, practice improvement is often used to refer to efforts to improve care within an individual practice whereas quality improvement is used to refer to broader, system-wide efforts. Practice improvement and quality improvement efforts can be used in primary care to reduce inefficiency and preventable errors, improve patient outcomes, and simultaneously increase patient and clinician satisfaction.9,10
Effectively implementing quality improvement (QI) in primary care requires disseminating the latest evidence to practices, as well as building practice capacity to implement changes to care based on that evidence. Ƶfunds patient-centered outcomes research to generate new evidence, as well as dissemination and implementation (D&I) research about how to translate and use evidence-based practices in clinical settings—including primary care.
Grants
Across AHRQ primary care research grants with active funding in FYs 2023 and 2024, 17 focus mainly on practice and quality improvement. This includes nine U18 grants (Research Demonstration / Cooperative Agreement), two R18 grants (Research Demonstration and Dissemination Projects), two R03 grants (Small Research Projects), two R13 grants (Conference), one R01 grant (Research Project), and one K01 award (Research Career Program).
Another 30 grants have some focus on practice and quality improvement and are described in other topic area sections, including six in Health Disparities, six in Patient Safety, five in Person-Centered Care, four in Digital Healthcare, four in Behavioral Health and Substance Use Disorders, three in Healthcare Systems and Infrastructure, and two in Public Health and Community Integration.
We summarize the 17 grants focused on practice and quality improvement below, organized by subtopic. The subtopics are:
- Managing Urinary Incontinence.
- Building State Capacity for QI.
- Evaluating Practice Improvements.
- Improving Care and Prevention for Cardiovascular Disease.
- Conference Grants.
Managing Urinary Incontinence
These five cooperative agreements are part of AHRQ’s EvidenceNOW: Managing Urinary Incontinence program. Read more about the overall EvidenceNOW initiative and learn about recent resources developed as a part of this program here.
(U18)
PIs: Joan Marie Neuner; Heidi Wendell Brown; Kathryn E. Flynn
Organization: Medical College of Wisconsin
Grant Start Date: February 1, 2022
Aims to increase the proportion of patients who are screened and offered treatment for urinary incontinence (UI) in 50 primary care practices. The intervention, called UI Assist, includes screening, education, and evidence-based treatment. The research team compares implementation of UI Assist alone or in combination with partnership building to help practices overcome barriers to intervention implementation.
(U18)
PIs: Adonis K. Hijaz; Goutham Rao
Organization: University Hospitals of Cleveland
Grant Start Date: February 1, 2022
Uses an integrated, multilevel approach to address key barriers to diagnosing and managing urinary incontinence in primary care. Implements the approach across a large network of primary care practices, including large-scale screening, empowering patients to discuss urinary incontinence with their clinicians, clinician education and training, practice facilitation through nurse navigation, and a “chatbot” to support patient self-management. The project also implements a system-based strategy for streamlined referrals and treatment.
Learn more about this study in a recent NCEPCR webinar: Research on Women’s Health in Primary Care.
(U18)
PIs: Stephen Persell; Kimberly Sue Kenton
Organization: Northwestern University at Chicago
Grant Start Date: February 1, 2022
This project’s multilevel implementation strategy aims to improve care for urinary incontinence for women in primary care through systematic and equitable screening, supporting patient-centered decision making for selecting treatment options, and accelerating the uptake of evidence-based nonsurgical treatment modalities. This project takes place in the largest health system in Illinois, with 65 primary care practices and 327 primary care physicians.
(U18)
PIs: Alayne Denise Markland; Elizabeth Camille Vaughan
Organization: University of Alabama at Birmingham
Grant Start Date: February 1, 2022
Aims to improve access for women Veterans in the southeastern United States to evidence-based, nonsurgical treatment for urinary incontinence. The study compares the effectiveness of the interactive treatment modality with or without additional urinary incontinence clinical expertise delivered via telehealth in 62 primary care practices that treat women Veterans. Participating practices receive practice facilitation support, training, and health information technology assistance. Researchers explore women Veterans’ and clinicians’ perceptions of remote urinary incontinence treatment to advise future scalability.
(U18)
PI: Jennifer Tash Anger
Organization: University of California, San Diego
Grant Start Date: February 1, 2022
Aims to improve the quality of urinary incontinence care provided to a diverse population of women in primary care, with the goals of improving care and reducing the need for specialty care. Includes three Southern California medical groups (a total of 60 clinics) in a practice-based incontinence intervention led by a “clinical champion dyad” comprising a primary care clinician and a urologist/urogynecologist for each medical group. Includes clinician education and performance feedback, electronic decision support, patient education from dedicated advanced practice clinicians, and an electronic referral service.
Building State Capacity for QI
These four grants fund the state-based cooperatives from AHRQ’s EvidenceNOW: Building State Capacity program. See more about the overall EvidenceNOW initiative and learn about recent resources developed as a part of this program here.
(U18) PIs: Shari Danielle Bolen; Aleece Caron
Organization: Case Western Reserve University
Grant Start Date: January 1, 2021
Expands a nascent statewide cardiovascular health collaborative in Ohio and establishes a sustainable external QI support infrastructure in the state. The project also implements and evaluates a QI intervention for heart health codesigned with primary care practices.
(U18)
PI: Andrea L. Cherrington
Organization: University of Alabama at Birmingham
Grant Start Date: January 1, 2021
Establishes the Alabama Cardiovascular Cooperative to coordinate statewide efforts to improve cardiovascular risk and reduce disparities. Additionally, implements a heart health improvement project in 60 primary care clinics throughout Alabama to improve rates of blood pressure control and screening for smoking status.
(U18)
PIs: Anya Day; Theresa L. Walunas
Organization: Altarum Institute
Grant Start Date: January 1, 2021
Establishes a statewide cooperative in Michigan to provide QI support to help primary care practices implement interventions to improve hypertension management and tobacco cessation. These efforts are coupled with optimization of health information technology and telehealth approaches to address barriers to access in rural parts of the state.
(U18)
PI: James E. Bailey
Organization: University of Tennessee Health Science Center
Grant Start Date: March 1, 2021
Establishes the Tennessee Heart Health Network (THHN), which leverages existing infrastructure to identify and implement evidence-based interventions to improve quality of care for cardiovascular disease in primary care across the state. THHN specifically targets hypertension control and smoking cessation to help reduce disparities in cardiovascular outcomes.
Evaluating Practice Improvements
Four grants test the implementation and uptake of approaches to improve quality in primary care.
(R01)
PIs: Mark Allen Clapp; Jessica Lee Cohen
Organization: Massachusetts General Hospital
Grant Start Date: September 30, 2024
Develops and evaluates an intervention to strengthen coordination and transition of obstetric and primary care for postpartum patients. The intervention consists of default scheduling for primary care visits, tailored nudge messages to patients, ongoing care recommendations sent to the primary care clinician, and giving a summary of after-pregnancy recommendations to the patient.
Learn more about this study in a recent NCEPCR webinar: Factors That Impact Perinatal Care Experiences and Outcomes.
(R18)
PI: Eric J. Thomas
Organization: University of Texas Health Science Center Houston
Grant Start Date: September 30, 2022
Assesses the implementation of a bundle of evidence-based interventions (EBIs) designed to reduce missed abnormal laboratory tests in primary care practice using a stepped wedge cluster randomized controlled trial (RCT). The EBIs to be implemented include automated abnormal test result detection and tracking, including clinical pathologists on primary care teams, and using nurse navigators to engage patients in the diagnostic process. The research team plans to examine the impact of the EBIs on patient safety and diagnostic efficiency; assess the acceptability, appropriateness, cost, and sustainability of the interventions; and identify facilitators and barriers to implementation.
(R03)
PI: Nathaniel David Hendrix
Organization: American Board of Family Medicine
Grant Start Date: September 30, 2024
Aims to help clinical guideline developers predict and improve the uptake and potential impact of primary care–relevant clinical guideline updates. The research team uses change-point analysis to assess predictors of guideline-concordant practice change for four recent clinician guideline updates, and then uses a multi-level model with patient, clinician, and practice site characteristics to predict the time to practice change. The team also uses latent class analysis to develop phenotypes of clinicians based on their responses to the four guideline updates to identify patterns of practice change. Finally, the team develops market segmentation and the individualized educational outreach to improve the efficiency and impact of dissemination activities based on the phenotypes.
(R03)
PI: Erin Fitzgerald Carlton
Organization: University of Michigan at Ann Arbor
Grant Start Date: July 1, 2023
Uses national multi-payer data to measure how often children have a primary care follow-up visit within seven days after a pediatric intensive care unit stay after experiencing a critical illness. The study also assesses disparities in primary care follow-up by patient age, comorbidities, and socioeconomic status and examines whether receipt of timely follow-up is associated with reduced 90-day acute healthcare utilization.
Improving Care and Prevention for Cardiovascular Disease
Two studies focused on QI for cardiovascular disease, in particular.
(K01)
PI: Edmond Ramly
Organization: Trustees of Indiana University
Grant Start Date: April 8, 2022
Aims to develop a customizable toolkit for implementing cardiovascular disease guidelines in primary care after telehealth expansion. The toolkit includes a menu of options to help practices address specific local barriers without requiring the engagement of an expert for a costly tailoring process.
(R18)
PIs: Elyse Olshen Kharbanda; Catherine Pastorius Benzinger
Organization: HealthPartners Institute
Grant Start Date: September 30, 2020
Compares high- and low-intensity interventions to implement an electronic health record–linked clinical decision support in rural primary care practices to provide evidence-based clinical care recommendations for blood pressure management in youth.
Learn more about this study in a Primary Care Research Profile: Identifying and Managing Hypertension Among Rural Youth (PDF, 291 KB).
Conference Grants
Ƶfunded two conferences to share evidence-based practices among primary care clinicians.
(R13)
PI: Allison Cole
Organization: NAPCRG (North American Primary Care Research Group)
Grant Start Date: April 1, 2023
Supports the NAPCRG’s 19th, 20th, and 21st meetings of practice-based research networks (PBRNs). Includes funding to help promote the meeting and then support the convening itself. Support includes coordinating, managing, and evaluating the event and then disseminating the results. The PBRN conferences help build the skills and knowledge of clinicians, researchers, and community partners in evidence-based research to improve the health of the U.S. population, healthcare delivery systems, and the quality of primary healthcare.
(R13)
PI: Christina Tortolani
Organization: Rhode Island College
Grant Start Date: September 30, 2023
Supports a research development conference to advance evidence-based care of pediatric eating disorders in primary care. Various presentations and breakout groups contribute to the development of a “research roadmap,” outlining priorities such as education needs and practical screening, diagnosis, and treatment decisions. Although primary care clinicians are often the first contact of families of children suffering from eating disorders, they are often undertrained in the assessment and management of these conditions. This conference is a first step in getting primary care clinicians the support they need to confidently identify, manage, and treat pediatric eating disorders. (Read for additional information on this topic and the conference proceedings).
Initiatives and Resources
AHRQ shares evidence-based resources for Practice Improvement, including tools, toolkits, and trainings. These resources include EvidenceNOW Tools for Change, a searchable database of tools that primary care practices can use to implement QI activities. Primary care-relevant resources released in 2023 and 2024 are described below.
EvidenceNOW
EvidenceNOW projects use the same model to provide external support to help primary care practices implement new evidence into care. The first EvidenceNOW project, Advancing Heart Health, ended in 2018, but three EvidenceNOW projects continued to be active during 2023 and 2024:
- EvidenceNOW: Managing Urinary Incontinence. Helped primary care practices implement evidence-based, nonsurgical treatments for urinary incontinence in women. Ƶfunded five grantees and a contract to support a learning community and program-wide evaluation. Project materials released in 2023 and 2024 include:
- Managing Urinary Incontinence for Women in Primary Care: Environmental Scan Report Update for the Managing Urinary Incontinence Initiative (PDF, 3.2 MB)
- Tools and Resources to Help Improve Urinary Incontinence Care for Women.
- Webinar: Managing Urinary Incontinence in Primary Care: Sharing Progress and Resources from AHRQ's EvidenceNOW Initiative.
- Webinar: Implementing Urinary Incontinence Management in Primary Care: Case Studies from AHRQ's EvidenceNOW Program.
- EvidenceNOW: Building State Capacity. Focused on building state capacity and infrastructure to support primary care practices with implementing evidence-based heart health interventions and decreasing health disparities. Ƶfunded four grantees and a technical assistance and evaluation center. Project-wide materials released in 2023 and 2024 are included below (go to EvidenceNOW: Tools and Resources for additional materials developed by the state cooperatives):
- Developing and Sustaining State-Based Infrastructure to Support Primary Care Quality Improvement - A How-To Guide (PDF, 5.7 MB).
- Building State Cooperatives for Healthcare Improvement: Meeting Summary.
- The Second Interim Evaluation Report can be found with other reports here (PDF, 1.8 MB).
- EvidenceNOW: Managing Unhealthy Alcohol Use. Worked to increase screening for unhealthy alcohol use in primary care, followed by a brief intervention and referral to treatment when indicated. Ƶfunded six grants as well as a Resource Center and evaluation contract. Project materials released in 2023 and 2024 include:
Practice-Based Research Network (PBRN) Resources
Ƶfunds an annual through the North American Primary Care Research Group (NAPCRG) and continues to host resources to support PBRNs, including a listserv and registry. In 2024, NCEPCR launched a learning series to support and promote the work of PBRNs. The learning series includes:
- An E-Learning Course: Building a Newer PBRN This self-paced e-learning course shares information and resources that are useful for audiences looking to set up a new PBRN or build an existing one.
- Two Webinars:
AHRQ’s initial investment in Heart of Virginia Healthcare, a regional cooperative participating in the EvidenceNOW: Advancing Heart Health program, led to additional work and investments by other funders – resulting in sustained efforts to improve the quality of primary care in Virginia.
Read a NCEPCR Impact Story to learn more about the Virginia Task Force on Primary Care, led by Beth Bortz: Bridging Gaps and Uniting Partners to Improve Primary Care in the Commonwealth of Virginia (PDF, 913 KB).
