EvidenceNOW: Virginia Cooperative

EvidenceNOW: Advancing Heart Health in Primary Care is an initiative of the Agency for Healthcare Research and Quality (AHRQ) to transform health care delivery by building a critical infrastructure to help smaller primary care practices improve the heart health of their patients by applying the latest medical research and tools. EvidenceNOW establishes seven regional cooperatives composed of public and private health partnerships that provide a variety of quality improvement services typically not available to small primary care practices. The goal of this initiative is to ensure that primary care practices have the evidence they need to help their patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure control, Cholesterol management, and Smoking cessation. The initiative also includes an independent national evaluation designed to determine if and how quality improvement support can accelerate the dissemination and implementation of new evidence in primary care.

The Commonwealth of VirginiaCooperative Name: Heart of Virginia Healthcare


Principal Investigator: Anton Kuzel, M.D., M.H.P.E., Virginia Commonwealth University

Cooperative Partners:
Virginia Commonwealth University
Virginia Center for Health Innovation
George Mason University
Center for Health Policy Development

Geographic Area: Virginia

Project Period: 2015–2018

Region and Population

Virginia has a population of more than 8.3 million people.1 Heart disease is the second leading cause of death. Although most of these deaths occur in the populous urban and suburban centers in Northern, Central, and Eastern Virginia, some of the highest age-adjusted death rates due to heart disease can be found in less populous rural areas, including medically underserved areas.2 Like the United States as a whole, Virginia experiences racial, ethnic, and economic disparities in access to care and effectiveness of care for cardiovascular disease (CVD).3,4

Specific Aims

  1. Accelerate the incorporation of patient-centered outcomes research (PCOR) findings (both clinical and organizational) into practice, with an initial focus on cardiovascular health and ABCS.
  2. Increase practices' capacity to integrate new PCOR findings on an ongoing basis.
  3. Help practices become more efficient and more patient-centered, and help physicians return to spending most of their time caring for patients.


  • Goal for Number of Primary Care Professionals Reached: 765–900.
  • Goal for Population Reached: 1.15–1.35 million.

Updates on Key Project Components

Support Strategy

The cooperative will offer practice facilitation in an intensive intervention and coaching phase (3 months) followed by a maintenance phase (9 months), and will have the following components:

  • Expert consultation to help practices solve specific challenges in quality improvement and practice transformation.
  • Collaborative learning events to help practices learn and implement PCOR findings and related practice improvements.
  • An online support center where practices can find and share announcements, ideas, insights, and promising practices. Online resources will include articles, tools, tutorials, and Webinars, plus data on community CVD indicators.
  • Data feedback and benchmarking. Practices will report on multiple dimensions of their experience, including ABCS measures, which will allow them to compare their performance to other practices and will inform their practice improvement efforts.


  • The kick-off event for the first cohort was held in February 2016 and the second was held in April 2016; the third is scheduled for August.
  • The intervention was successfully rolled out for the first cohort and is beginning for the second. During the intensive phase, practice facilitators have at least ne contact a week with their practices. During the maintenance phase, practice facilitators are available for remote consults or in-person meetings as needed by the practice.
  • A full set of practice improvement and patient education materials is handed out during the kickoff, but facilitators and practices decide where to focus their transformation efforts during their one-on-one meetings. A primary focus of the meetings is developing strategies to make the provision of primary care more efficient and patient-centered so as to restore the "joy in practice."
  • Facilitators are helping practices understand how EvidenceNOW aligns with and reinforces other quality improvement efforts, such as commercial plan reporting requirements and requirements of Accountable Care Organizations, Patient-Centered Medical Homes, or other payers and programs.


The cooperative is using a stepped-wedge design with three intervention cohorts (3 months each of weekly coaching, plus 9 more months of active support), with practices stratified by geographic region and then randomized to a specific wedge and intervention start date (February, May, or August 2016).


  • Virginia has devised a new strategy for ABCS data extraction, and the evaluation team is establishing custom reporting solutions for practices and networks of practices working with different electronic health record vendors.
  • Data are returned to practice facilitators for use in practice improvement, and the team is developing a dashboard platform for practices and facilitators to track progress over time.

Strategies for Disseminating Study Findings and Lessons Learned


  • The cooperative is developing issues briefs and, in partnership with the National Academy for State Health Policy, is currently planning ways to disseminate findings and lessons learned through traditional and social media channels.
  • The cooperative plans four to five early papers, some of which will be Virginia-specific and some of which will be in collaboration with the other cooperatives.

Spotlight on Recruitment

Comment From Principal Investigator

Anton Kuzel, M.D., M.H.P.E.

"Our value proposition, which focused on restoring joy to practice, was somewhat helpful. The relatively significant payments for providing data and completing surveys was particularly helpful in practice networks. Some practices also saw our initiative as providing free coaching to help them prepare for a post-MACRA world. Unfortunately, some practices were at such an advanced stage of burnout that they couldn't choose to grab the lifeline we were offering."

Recruitment Specifics

The cooperative's recruitment process successfully concluded on March 30, 2016, with 249 practices enrolled. Recruited practices represent five regions across Virginia, but most are located in Richmond.

Factors That Contributed to Recruitment Success

  • Relationships: Personal connections were critical. The cooperative leveraged faculty relationships and Virginia Center for Health Innovation connections to help practices understand the benefits of participation.
  • "Joy in practice" focus: The Team worked with Drs. Tom and Christine Sinsky, general internists who lecture on "restoring the joy to primary care practice," to make the argument that participation could help practices increase value, work smarter, enhance patient-centered care, and prepare for new policies and requirements. The kick-off event was an important venue for presenting this focus.
  • Flexibility: The team made some adjustments to its recruitment messaging and approach to make participation attractive, such as clarifying the value of EvidenceNOW in the context of other State and Federal initiatives, paying for data extraction, and allowing some practices to join the kick-off remotely.
  • Link to other initiatives/payment reform: Practices learned that EvidenceNOW is a mechanism that can help them become engaged in various practice transformation initiatives. This is particularly important for small practices because of their limited infrastructure for quality improvement and performance measurement efforts. An important message for the practices is that their participation is "bigger" than Virginia—their participation is making a difference for a significant national initiative.

Challenges to Recruitment and How the Cooperative Responded

  • Competing initiatives: The team created a comparison of EvidenceNOW and a competing practice transformation initiative in the State. Helping practices understand the complementary elements of the initiatives and using the same practice facilitators for each, to the extent possible, increased practices' interest in joining EvidenceNOW.
  • Primary care burnout: The cooperative's focus on "restoring the joy to practice," workflow redesign, and team-based care reduced practices' concern about possible burdens of participation.
  • Randomization design: Practice networks did not want to participate if they would be divided across cohorts. Altering the criteria for stratification, such as randomizing groups of practices from a network in a similar geographic location, addressed this concern.
  • Timeline: Changing to a shorter 3-month intensive intervention with a 9-month maintenance period allowed all practices to have a start date in 2016 and gave the cooperative extra time to recruit and randomize practices in cohorts two and three.

1 http://quickfacts.census.gov/qfd/states/37000.html. Accessed May 24, 2016.
2 http://atlasva.org. Accessed April 26, 2015.
3 Virginia Health Equity Report, 2012. Richmond (VA): Virginia Department of Health.; 2012. http://www.vdh.virginia.gov/OMHHE/Documents/Health%20Equity%20Report.pdf. Accessed April 26, 2015.
4 http://nhqrnet.ahrq.gov/inhqrdr/reports/index. Accessed April 26, 2015

Page last reviewed October 2016
Page originally created October 2016
Internet Citation: EvidenceNOW: Virginia Cooperative. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/evidencenow/cooperatives/virginia-cooperative.html