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A Randomized Trial of Practice-Based Education to Improve Delivery Systems for Anticipatory Guidance
Marjorie S. Rosenthal, MD;
Carole M. Lannon, MD, MPH;
Jayne M. Stuart, MPH;
Laura Brown, MPH;
William C. Miller, MD, PhD;
Peter A. Margolis, MD, PhD
Arch Pediatr Adolesc Med. 2005;159:456-463.
Background Communication between physicians and patients is an important component of medical encounters and has been identified by the Institute of Medicine as a point of intervention to increase quality of care. In pediatric health maintenance visits, substantial recommended communication, in the form of anticipatory guidance, is not provided.
Objective To examine the effectiveness of an intervention of continuing medical education and process improvement methods to implement "office systems" to improve the delivery of anticipatory guidance for parents of young children.
Methods We performed a randomized controlled trial of a practice-based quality improvement intervention among 44 pediatric practices in North Carolina. In the 22 intervention practices, project staff coached practice staff in auditing performance and identifying, testing, and implementing new care processes to improve delivery of anticipatory guidance. We surveyed parents of 1-month-olds and 6-month-olds regarding their recollection of anticipatory guidance as well as parent knowledge and parent behaviors and used cluster analysis to determine the effects of the intervention.
Results The proportion of parents of 1-month-olds who reported that they received all age-appropriate anticipatory guidance changed from 15.9% (95% confidence interval [CI], 8.9%-26.7%) to 10.0% (95% CI, 5.1%-18.8%) in the control practices and from 7.3% (4.1%-12.9%) to 24.0% (95% CI, 14.6%-36.9%) in the intervention practices (difference between 2 differences, P = .002). The proportion of parents of 6-month-olds who reported that they received all age-appropriate anticipatory guidance changed from 8.2% (95% CI, 3.6%-17.8%) to 5.4% (95% CI, 2.8%-10.2%) in the control practices and from 2.2% (95% CI, 0.8%-5.9%) to 18.1% (95% CI, 10.3%-29.9%) in the intervention practices (difference between 2 differences, P = .001). There were no differences in self-reported parent knowledge and parent behavior.
Conclusion An office system intervention improved parent reports of quantity of anticipatory guidance but did not change parent knowledge or parent behavior. Future research should examine how to use systems improvement methods to improve the impact of anticipatory guidance.
Author Affiliations: From the Robert Wood Johnson Clinical Scholars Program (Drs Rosenthal and Miller), Division of General Pediatrics and Adolescent Medicine (Drs Rosenthal, Lannon and Margolis), Center for Children's Healthcare Improvement (Drs Lannon and Margolis and Mss Stuart and Brown), and Department of Epidemiology, School of Public Health (Drs Miller and Margolis), University of North Carolina at Chapel Hill. Dr Rosenthal is now with the Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Conn.
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