EvidenceNOW Publications


Follow EvidenceNOW publications and stay up to date with the latest findings from the initiative on key topics in research and primary care quality improvement.


Primary Care Landscape

The Influence of a Place-Based Foundation and a Public University in Growing a Rural Health Workforce

The Southwest Cooperative worked with the University of New Mexico’s Office of Community Health, which hired local Health Extension Rural Officers (HEROs) in different regions of the State to link community health needs with university resources. Multi-party agreements involved the JF Maddox foundation, a local community college, local community hospitals, and the University to work together to recruit, support, and retain local health care professionals in an impoverished, rural area of the State. These partnerships significantly increased recruitment of key health care professionals, developed a more cohesive medical community, established a school-based clinic, and provided support for other community challenges. The University has since exported this model to other rural communities in the State.

Reid R, Rising E, Kaufman A, et al. The influence of place-based foundation and a public university in growing a rural health workforce. J Comm Hlth 2019; 44:292-296. Available at: https://doi.org/10.1007/s10900-018-0585-y

Use of Quality Improvement Strategies Among Small- to Medium-Size U.S. Primary Care Practices

The EvidenceNOW National Evaluation Team assessed the use of quality improvement strategies by small- to medium-sized primary care practices before participating in EvidenceNOW. Practices that participated in accountable care organizations, produced reports from electronic health records (EHRs), produced quality reports, or discussed clinical quality data in meetings use quality improvement (QI) strategies to a greater degree than other practices. Additionally, they found lower use of QI strategies among health-system owned practices and those experiencing a disruptive event.

Balasubramanian BA, Marino M, Cohen DJ, et al. (2018). Use of quality improvement strategies among small- to medium-size US primary care practices. Ann Fam Med 2018;16(Suppl 1):S35-S43. http://www.annfammed.org/content/16/Suppl_1/S35.

A primary care clinician reviews information with a patientPrimary Care Practices’ Abilities and Challenges Using Electronic Health Record Data for Quality Improvement

An analysis of the challenges primary care practices face in generating and using data reports from their electronic health records (EHRs) to conduct quality improvement activities. The EvidenceNOW National Evaluation Team found that meaningful-use participation was associated with the ability to generate reports on clinical quality measures, but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, including functionality limitations, differences between clinical guidelines and measures available in EHR-generated reports, and questionable data quality. Findings from this large study of smaller primary care practices demonstrate that the promise of using EHRs for quality improvement remains largely unfulfilled.

Cohen, DJ et al. (2018). Health Affairs 37(4). https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.1254.

Effect of Practice Ownership on Work Environment, Learning Culture, Psychological Safety, and Burnout

The Virginia Cooperative examines effects of practice ownership on self-reported work environment, culture of learning, psychological safety, and burnout at small- and medium-size primary care practices. Hospital ownership was associated with more positive perceptions of practice work environment, psychological safety, and lower staff burnout, though the effect was largely driven by clinic staff rather than clinicians.

Cuellar A, Krist AH, Nichols LM, Kuzel AJ. (2018). Association between primary care practice ownership, work environment, learning culture, and burnout. Ann Fam Med 2018;16(Suppl 1):S44-S51. http://www.annfammed.org/content/16/Suppl_1/S44.

Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study

The North Carolina Cooperative examines small primary care practices’ performance on blood pressure control goals before practices’ participation in EvidenceNOW and the relationship to organizational quality improvement (QI) characteristics. Adaptive reserve and leadership capability in QI were not associated with achieving the target blood pressure goal.

Henderson KH, DeWalt DA, Halladay J, et al. (2018). Organizational leadership and adaptive reserve in blood pressure control: The Heart Health NOW Study. Ann Fam Med 2018;16(Suppl 1):S29-S34. http://www.annfammed.org/content/16/Suppl_1/S29.

EvidenceNOW: Balancing Primary Care Implementation and Implementation Research

AHRQ describes the research design decisions made for the EvidenceNOW initiative, including the focus on small- and medium-sized practices, the specific intervention and research strategies, the evaluation, and use of learning communities. The article also addresses the trade-offs between research goals and real-world implementation of quality improvement strategies.

Meyers D, Miller T, Genevro J, et al. (2018). EvidenceNOW: Balancing primary care implementation and implementation research. Ann Fam Med 2018;16(Suppl 1):S5-S11. http://www.annfammed.org/content/16/Suppl_1/S5.

The Alarming Rate of Major Disruptive Events in Primary Care Practices in Oklahoma

The Oklahoma Cooperative explores major disruptive events in small- to medium-sized primary care practices in Oklahoma, such as practice relocation, changes in ownership and key staff, and implementation of new systems—events that can affect quality and continuity of care. During the practices’ first year participating in EvidenceNOW, nearly one in two practices experienced at least one major disruptive event.

Mold JW, Walsh M, Chou A, Homco J. (2018). The alarming rate of major disruptive events in primary care practices in Oklahoma. Ann Fam Med 2018;16(Suppl 1):S52-S57. http://www.annfammed.org/content/16/Suppl_1/S52.

Quality of Cardiovascular Disease Care in Small Urban Practices

This paper by the New York City Cooperative captures the performance of small, urban primary care practices on the four EvidenceNOW heart health care (ABCS) measures before the practices participated in EvidenceNOW. At these practices, performance on goals for the ABCS of heart health varied. Researchers also found that solo clinician primary care practices were more likely to meet the aspirin and cholesterol goal than practices with more than one clinician.

Shelley D, Blechter B, Siman N, et al. (2018). Quality of cardiovascular disease care in small urban practices. Ann Fam Med 2018;16(Suppl 1):S21-S28. http://www.annfammed.org/content/16/Suppl_1/S21.

AHRQ’s EvidenceNOW: A Snapshot of Participating Primary Care Practices

An infographic showing diversity among primary care practices participating in EvidenceNOW across characteristics such as practice size, location, ownership, and patient characteristics.

Agency for Healthcare Research and Quality. (September 2017). Available at: http://www.ahrq.gov/evidencenow/evaluation/practice-snapshot.html.

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Practice Facilitation

Facilitating Practice Transformation in Frontline Health Care

This editorial by EvidenceNOW grantees notes that many featured papers in this supplement on primary care transformation are the early products of nearly $800 million invested by AHRQ and other Federal health agencies to test facilitation of transformation in thousands of practices across the United States. It notes that most small practices lack the time, energy, and resources for quality improvement and lack examples from which they can learn. Farmers were in this position a century ago when the U.S. Department of Agriculture Cooperative Extension Program revolutionized farming in the United States. Agricultural experts worked with farmers to test and disseminate innovative agricultural practices that farming is still benefitting from today. AHRQ has developed a similar extension model using practice facilitators and other consultants and resources to transform primary care, which is described in several supplement articles by EvidenceNOW researchers in this supplement.

Phillips Jr, RL, Cohen DJ, Kaufman A, et al. (2019).Facilitating practice transformation in frontline health care. Ann Fam Med 2019; 17 (Suppl 1):S2-S5. http://www.annfammed.org/content/17/Suppl_1/S2.full

Clinician Perspectives on the Benefits of Practice Facilitation for Small Primary Care Practices

The Healthy Hearts New York City Cooperative interviewed 19 small independent primary care practices (SIPs) about how the benefits of practice facilitation (PF) differed based on the availability of internal staff for quality improvement. Providers perceived three central PF benefits: creating awareness of quality gaps; connecting practices to information, resources, and strategies to improve care; and optimizing the EHR for quality improvement goals. SIPS with more than three office staff felt PF provided benefits primarily through teaching, while SIPs with three or fewer staff felt that PF also provided hands-on support.

Rogers ES, Cuthel AM, Berry CA, et al. Clinician perspectives on the benefits of practice facilitation for small primary care practices. Ann Fam Med 2019; 17 (Suppl 1):S17-S23. http://www.annfammed.org/content/17/Suppl_1/S17.full

A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care

The Northwest Cooperative compared the effectiveness of adding enhanced external support to practice facilitation (PF) on primary care practices’ performance on cardiovascular clinical quality measures. In this randomized trial, Practices received either PF alone or enhanced practice support that included: PF with shared learning opportunities, PF with educational outreach visits, or PF with both shared learning opportunities and educational outreach visits. The researchers found no significant differences in clinical quality measure improvements between practices receiving only PF and those receiving enhanced support. However, they found that practices that received both shared learning opportunities and educational outreach were two times more likely to achieve a blood pressure performance goal of 70 percent compared to those receiving PF alone.

Parchman ML, Anderson ML, Dorr DA, et al. A randomized trial of external practice support to improve cardiovascular risk factors in primary care. Ann Fam Med 2019; 17 (Suppl 1):S40-S49. http://www.annfammed.org/content/17/Suppl_1/S40.full

A practice facilitator talks to a group of primary care clinicians.Practice Facilitators’ and Leaders’ Perspectives on a Facilitated Quality Improvement Program

A qualitative look by the Midwest Cooperative at methods for improving quality improvement approaches, using detailed interviews from primary care practice leaders and the practice facilitators assigned to those practices. Interviews indicated that targeted practice facilitator-supported efforts may be easier to implement in primary care than larger, more extensive quality improvement projects.

McHugh M, Brown T, Liss DT, Walunas T, Persell S. (2018). Practice facilitators' and leaders' perspectives on a facilitated quality improvement program. Ann Fam Med 2018;16(Suppl 1):S65-S71. http://www.annfammed.org/content/16/Suppl_1/S65.

A Framework to Guide Practice Facilitators in Building Capacity

A discussion from the North Carolina Cooperative of a new framework for practice facilitators to apply the most appropriate mechanism for providing information to primary care practices, with a goal of building practices’ capacity to sustain improvement in their care delivery.

Baker N, Lefebvre A, Sevin C. (August 2017). J Family Med Community Health 4(6):1126. Available at: https://www.jscimedcentral.com/FamilyMedicine/familymedicine-4-1126.pdf.

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Practice Capacity for Quality Improvement

Assessing Quality Improvement Capacity in Primary Care Practices

Healthy Hearts Northwest developed a Quality Improvement Capacity Assessment (QICA) survey that identified seven domains of QI capacity, such as embedding clinical evidence into daily work and using data to improve clinical performance measures. As part of the study intervention, each of the 209 participating practices met with a practice facilitator (PF) to discuss their survey responses and calculate a QICA score. The researchers examined the association between the QICA scores, practice characteristics, their prior experience with managing practice change, and performance on clinical quality measures for three cardiovascular (CVD) risk factors. The QICA score was associated with prior experience managing change and moderately associated with two of three CVD risk factors. Rural practices and those with 2 to 5 clinicians had lower QICA scores. The authors conclude that the QICA is useful for assessing QI capacity within a practice and may serve as a guide for both PFs and practices to improve QI capacity and clinical performance.

Parchman ML, Anderson ML, Coleman K, et al. Assessing quality improvement capacity in primary care practices. BMC Family Practice 2019; 20:103. Available at: https://doi.org/10.1186/s12875-019-1000-1

Hands pointing to a clipboard and sheets of paper showing numbers and charts.AHRQ’s EvidenceNOW: Helping Small Primary Care Practices Build Capacity for Quality Improvement

An infographic highlighting participating EvidenceNOW practices’ capacity at baseline to implement new evidence into practice. Capacity refers to the attitudes, skills, structures, and processes that enable a primary care practice to improve systematically.

Agency for Healthcare Research and Quality. (January 2018). Available at: http://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/evaluation/evidence-now-improving-capacity.pdf.

A Framework to Guide Practice Facilitators in Building Capacity

A discussion from the North Carolina Cooperative of a new framework for practice facilitators to apply the most appropriate mechanism for providing information to primary care practices, with a goal of building practices’ capacity to sustain improvement in their care delivery.

Baker N, Lefebvre A, Sevin C. (August 2017). Journal of Family Medicine and Community Health 4(6):1126. Available at: https://www.jscimedcentral.com/FamilyMedicine/familymedicine-4-1126.pdf.

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Improving the ABCS of Heart Health

An older adult woman gets her blood pressure taken at the doctor’s office.

AHRQ’s EvidenceNOW: Setting the Target for Improving Heart Health in America

An infographic summarizing participating primary care practices’ performance delivering heart health services to their patients at baseline (as of January 2017).

Agency for Healthcare Research and Quality. (February 2017). Available at: http://www.ahrq.gov/evidencenow/evaluation/before-evidencenow.html.


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Research Design and Methods

A Population Approach Using Cholesterol Imputation to Identify Adults with High Cardiovascular Risk: A Report from AHRQ’s EvidenceNow Initiative

Using two different methods for estimating patients’ risk for cardiovascular disease, when cholesterol data are missing, can quickly and accurately identify high-risk patients, according to this study by AHRQ EvidenceNOW researchers in North Carolina. Using these methods could help clinicians avoid delays in implementing strategies to help reduce the cardiovascular risk for these patients.

Cykert S, DeWalt, DA, Weiner BJ, Pignone M, Fine J, and Kim, JI (2018). A population approach using cholesterol imputation to identify adults with high cardiovascular risk: A report from AHRQ’s EvidenceNow initiative.

Journal of the American Medical Informatics Association, November 29, 2018. https://doi.org/10.1093/jamia/ocy151

A Community Engagement Method to Design Patient Engagement Materials for Cardiovascular Health

The Southwest Cooperative describes research design challenges and findings from the use of a community-based intervention called Boot Camp Translation. This intervention focuses on translating evidence-based heart disease prevention strategies into messaging and materials that are relevant and understandable for community members. Findings indicate that this technique yielded messages and materials tailored to different communities, suggesting that heart disease prevention programs are not one-size-fits-all.

English A, Dickinson L, Zittleman L, et al. (2018). A community engagement method to design patient engagement materials for cardiovascular health. Ann Fam Med 2018;16(Suppl 1):S58-S64. http://www.annfammed.org/content/16/Suppl_1/S58.

Engaging Primary Care Practices in Studies of Improvement: Budgeting for Practice Recruitment

In this article, the Northwest and Midwest Cooperatives describe the approach, cost, and resources needed to recruit and enroll 500 primary care practices for EvidenceNOW. The recruitment effort required a total of 22,430 hours and $2.675 million, or $5,529 per enrolled practice. Prior relationships with practices or “warm hand-offs” predicted recruitment success.

Fagnan LJ, Walunas T, Parchman ML, et al. (2018). Engaging primary care practices in studies of improvement: budgeting for practice recruitment. Ann Fam Med 2018;16(Suppl 1):S72-S79. http://www.annfammed.org/content/16/Suppl_1/S72.

A hand holding a pen pointing to graphs on a computer screen.Recruiting Practices for Change Initiatives Is Hard: Findings from EvidenceNOW

A cross-cooperative analysis conducted by the EvidenceNOW National Evaluation Team of strategies used to recruit primary care practices into EvidenceNOW. The analysis explores important elements of primary care practice today that highlight the need for ever-changing recruitment methods.

Sweeney, S et al. (September 2017). American Journal of Medical Quality. Available at:  http://journals.sagepub.com/eprint/sktm6QrtsVRTST5dgKgM/full#articleCitationDownloadContainer.

Study Protocol for “Healthy Hearts Northwest”: a 2x2 Randomized Factorial Trial to Build Quality Improvement Capacity in Primary Care

A description of the EvidenceNOW Northwest Cooperative’s study protocol. The study targeted the enrollment of 250 smaller primary care practices across Washington, Oregon, and Idaho to assess four combinations of practice support—practice facilitation alone, practice facilitation with educational outreach, practice facilitation with shared learning opportunities, or practice facilitation with both—and their effectiveness in building quality improvement capacity in primary care.

Parchman, ML et al. (October 2016). Implementation Science 1(1):138. Available at: http://implementationscience.biomedcentral.com/articles/10.1186/s13012-016-0502-7.

Testing the Use of Practice Facilitation in a Cluster Randomized Stepped Wedge Design Trial to Improve Adherence to Cardiovascular Disease Prevention Guidelines: HealthyHearts NYC

A description of the EvidenceNOW New York City Cooperative’s study protocol. The study tested the use of a stepped-wedge cluster randomized control trial in evaluating the impact of practice facilitation versus usual care on the outcome of ABCS measures in 250 small- to medium-sized primary care practices in New York City.

Shelley, DR et al. (July 2016). Published in Implementation Science 11(1):88. Available at: http://implementationscience.biomedcentral.com/articles/10.1186/s13012-016-0450-2.

A National Evaluation of a Dissemination and Implementation Initiative to Enhance Primary Care Practice Capacity and Improve Cardiovascular Disease Care: the ESCALATES Study Protocol

An overview of the EvidenceNOW national evaluation research design. The observational study is examining quantitative and qualitative data across the seven EvidenceNOW cooperatives. Data collected will include information from online implementation diaries, interviews with practice staff, organizational characteristics, and performance on clinical quality measures (ABCS).

Cohen, DJ et al. (June 2016). Implementation Science 11(1): 86. Available at: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-016-0449-8.

Advancing Heart Health in North Carolina Primary Care: the Heart Health NOW Study Protocol

A description of the EvidenceNOW North Carolina Cooperative’s study protocol. The study used a stepped wedge, stratified, cluster randomized trial to determine the effect of a comprehensive, evidence-based practice support strategy—including practice facilitation, expert consultation, technology support, and regional learning collaboratives—on the implementation of evidence-based heart disease prevention among patients in 300 primary care practices.

Weiner, BJ et al. (November 2015). Implementation Science 10:160. Available at: http://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0348-4.

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Other Topics

Primary Care Practices’ Implementation of Patient-Team Partnerships: Findings from EvidenceNOW Southwest

EvidenceNOW Southwest provided 9 months of practice facilitation and information technology support to 211 Colorado and New Mexico primary care practices. The researchers analyzed surveys from participating practices on patient-team partnership activities of self-management support, patient social needs assessment, community resource linkages, and patient input to examine relationships between practice characteristics and patient-team partnership. They found that practices that used patient registries, were in a medically underserved area, had a multispecialty staff mix, and were using clinical cardiovascular disease management guidelines were significantly associated with greater patient-team partnerships. However, practices reported only partial implementation of patient-team partnership strategies, and could improve their assessment of patients’ social needs, incorporating patient expectations, and linking patients to community resources.

Hall TL, Knierim KE, Nease Jr. D, et al. Primary care practices’ implementation of patient-team partnerships: Findings from EvidenceNOW Southwest. JABFM July 2019; 32(4): 490-504. Available at: https://www.jabfm.org/content/32/4/490.full

The Role of Health Extension in Practice Transformation and Community Health Improvement: Lessons from 5 Case Studies

The Northwest, Southwest, and Oklahoma Cooperatives examined the effects of incorporating technical assistance for practices and their communities to address social determinants of health in five States: New Mexico, Oklahoma, Oregon, Colorado, and Washington. They interviewed the leaders of health extension initiatives in these States to describe case studies that stretched the boundaries of the primary care extension model. The findings reveal the importance of building sustained relationships with practices and community coalitions, documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders, understanding that health extension is a function that can be carried out by an individual or group depending on resources, and the importance of being prepared for political struggles over “turf” and “ownership” of extension. All authors saw the need for long-term sustained funding beyond grants for sustainability of quality improvement.

Kaufman A, Dickinson WP, Fagnan LJ, et al. The role of health extension in practice transformation and community health improvement: Lessons from 5 case studies. Ann Fam Med 2019; 17 (Suppl 1):S67-S72. http://www.annfammed.org/content/17/Suppl_1/S67.full

A doctor writes down information on a clipboard.

Virtual Educational Outreach Intervention in Primary Care Based on the Principles of Academic Detailing

This article describes the development by Healthy Hearts Northwest of a tailored virtual educational outreach program using principles of traditional academic detailing (AD). The program was adapted and deployed with small- and medium-sized rural and urban primary care practices across three States. The aim of the program was to increase practices' use of cardiovascular disease risk calculation and prescription of statins for primary prevention, when appropriate. The adapted virtual program has general application to the implementation of educational outreach interventions into geographically dispersed practices and can help overcome the limitations posed by more traditional resource-intensive AD programs.

Baldwin L-M, Fischer MA, Powell J, et al. (2018). Virtual educational outreach  intervention in primary care based on the principles of academic detailing. JCEHP 2018; a38(4):269-275. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30346338.

Data-Driven Diffusion of Innovations: Successes and Challenges in 3 Large-Scale Innovative Delivery Models

A paper by the Northwest Cooperative exploring barriers and solutions for diffusing data-driven innovations in primary care. The authors found that many health care organizations are using technologies necessary for health care innovation, such as electronic health records. However, for a variety of reasons, organizations encounter challenges with using data from those sources to drive innovations in care. Proposed solutions to these challenges include facilitating peer-to-peer technical assistance, providing data feedback reports to clinicians, and working with practice facilitators who are skilled in using data technology for quality improvement.

Dorr, D, Cohen, DJ, and Adler-Milstein, J. (2018). Health Affairs 37(2):257–265. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5810405/.

Taking Innovation to Scale in Primary Care Practices: The Functions of Healthcare Extensions

The EvidenceNOW National Evaluation team describes how EvidenceNOW cooperatives varied in their approaches to health care extension—a way of providing external support to primary care practices with the goal of spreading innovations. This paper provides early evidence that health care extension is a feasible and potentially useful approach for providing coordinated quality improvement support to primary care practices.

Ono, S et al. (2018). Health Affairs 37(2):222-230. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805471/.

Lessons in Advancing Evidence-Based Primary Care from the Heart of Virginia Healthcare EvidenceNOW Cooperative

This brief from the Virginia Cooperative shares challenges and successful strategies for implementing primary care quality improvement interventions, with lessons learned from EvidenceNOW. Major challenges included recruiting busy practices and extracting data on heart health measures. Successful strategies included leveraging and strengthening key relationships, as well as aligning quality improvement initiatives with other ongoing priorities for a practice.

Reck, J and Bacon, O. (2018). Published by the National Academy for State Health Policy. Available at: https://nashp.org/wp-content/uploads/2018/01/VCU-Brief-No-2.pdf.

Primary Care Provider Burnout: Implications for States & Strategies for Mitigation

A paper on the experiences of primary care practices participating in the EvidenceNOW Virginia Cooperative, which point to a number of practice challenges contributing to burnout including scope of practice, payment reform, reporting requirements, and electronic health records. This brief outlines a range of strategies and policy options that States have for mitigating burnout.

Reck, J. (2017). Published by the National Academy for State Health Policy. Available at: http://nashp.org/primary-care-provider-burnout-implications-for-states-strategies-for-mitigation.

Page last reviewed August 2019
Page originally created March 2018
Internet Citation: EvidenceNOW Publications. Content last reviewed August 2019. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/evidencenow/research-results/results/publications.html
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