Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial

BMC Family Practice

Research Article

Kevin E Thorpe¹  Muhammad Mamdani²  Jess Rogers³  Jaclyn Beca⁴  Jeffrey S Hoch⁵  Rahim Moineddin⁶  Christopher Meaney⁶  Paul Krueger⁶  Eva Grunfeld⁷  Denise Campbell-Scherer⁸  Donna Manca⁸ 

[1] Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 193 Yonge Street, M5B 1M8, Toronto, Ontario, Canada;Dalla Lana School of Public Health, University of Toronto, Toronto, Canada;Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 193 Yonge Street, M5B 1M8, Toronto, Ontario, Canada;Institute for Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada;Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada;Centre for Effective Practice, 203 College Street, Suite 402, M5T 1P9, Toronto, Canada;Centre for Excellence in Economic Analysis Research, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond Street, M5B 1W8, Toronto, Canada;Pharmacoeconomics Research Unit, Cancer Care Ontario, Toronto, Canada;Centre for Excellence in Economic Analysis Research, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond Street, M5B 1W8, Toronto, Canada;Pharmacoeconomics Research Unit, Cancer Care Ontario, Toronto, Canada;Institute for Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada;Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada;Department of Family Community Medicine, University of Toronto, 500 University Avenue, M5G 1V7, Toronto, Ontario, Canada;Department of Family Community Medicine, University of Toronto, 500 University Avenue, M5G 1V7, Toronto, Ontario, Canada;Ontario Institute for Cancer Research, Toronto, Ontario, Canada;Department of Family Medicine, University of Alberta, 901 College Plaza, T6G 2C8, Edmonton, Alberta, Canada;

关键词: Primary care;    Family practice;    Pragmatic trial;    Chronic disease prevention;    Cancer screening;    Facilitation;   

DOI  :  10.1186/1471-2296-14-175

 received in 2013-06-24, accepted in 2013-11-07,  发布年份 2013

来源: Springer

【 摘 要 】

BackgroundPrimary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care.MethodsPragmatic two-way factorial cluster RCT with Primary Care Physicians’ practices as the unit of allocation and individual patients as the unit of analysis. The setting was urban Primary Care Team practices in two Canadian provinces. Eight Primary Care Team practices were randomly assigned to receive the practice-level intervention or wait-list control; 4 physicians in each team (32 physicians) were randomly assigned to receive the patient-level intervention or wait-list control. Patients randomly selected from physicians’ rosters were stratified into two groups: 1) general and 2) moderate mental illness. The interventions involved a multifaceted, evidence-based, tailored practice-level intervention with a Practice Facilitator, and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored ‘prevention prescription’. The primary outcome was a composite Summary Quality Index of 28 evidence-based chronic disease prevention and screening actions with pre-defined targets, expressed as the ratio of eligible actions at baseline that were met at follow-up. A cost-effectiveness analysis was conducted.Results789 of 1,260 (63%) eligible patients participated. On average, patients were eligible for 8.96 (SD 3.2) actions at baseline. In the adjusted analysis, control patients met 23.1% (95% CI: 19.2% to 27.1%) of target actions, compared to 28.5% (95% CI: 20.9% to 36.0%) receiving the practice-level intervention, 55.6% (95% CI: 49.0% to 62.1%) receiving the patient-level intervention, and 58.9% (95% CI: 54.7% to 63.1%) receiving both practice- and patient-level interventions (patient-level intervention versus control, P < 0.001). The benefit of the patient-level intervention was seen in both strata. The extra cost of the intervention was $26.43CAN (95% CI: $16 to $44) per additional action met.ConclusionsA Prevention Practitioner can improve the implementation of clinically important prevention and screening for chronic diseases in a cost-effective manner.

【 授权许可】

CC BY   
© Grunfeld et al.; licensee BioMed Central Ltd. 2013