Published online August 31, 2007
PEDIATRICS Vol. 120 No. 3 September 2007, pp. e644-e650 (doi:10.1542/peds.2006-1749)
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ARTICLE

Effectiveness of a Practice-Based, Multimodal Quality Improvement Intervention for Gastroenteritis Within a Medicaid Managed Care Network

Adam J. Zolotor, MD, MPHa, Greg D. Randolph, MD, MPHb, Julie K. Johnson, PhD, MSPHc,d, Steven Wegner, MD, JDe, Lori Edwards, MPH, APRN, BCf, Carol Powell, MSN, RNg and Megan H. Esporas, BAg

a Departments of Family Medicine
b Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
c Department of Medicine, University of Chicago, Chicago, Illinois
d American Board of Medical Specialties, Evanston, Illinois
e AccessCare, Inc, Morrisville, North Carolina
f Johns Hopkins University School of Nursing, Baltimore, Maryland
g Center for Health Care Quality, Cincinnati Children's Hospital and Medical Center, Cincinnati, Ohio


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. Acute gastroenteritis results in 220000 hospitalizations yearly in the United States. The substantial geographic variation in gastroenteritis care, coupled with the evidence of effective treatment of dehydration in nonhospital settings, suggests that the majority of these hospitalizations are avoidable. We sought to decrease hospitalizations for gastroenteritis by using practice-based, multimodal quality improvement methods that target multiple care processes to make them consistent with evidence-based guidelines.

METHODS. We used a controlled before/after study design to evaluate a quality improvement intervention in a 20-practice Medicaid network. All 20 practices participated in continuing education sessions; received free oral rehydration solution, patient education materials, and performance feedback; and participated in a follow-up conference call. Three practices were chosen to develop and pilot office-process changes. These practices formed interdisciplinary teams to develop and test changes and collaborated with project faculty and each other. They shared their learning with the other 17 practices via a conference call and toolkit. We compared before/after gastroenteritis hospital admissions for children <5 years old covered by Medicaid in the intervention practices with all other Medicaid recipients in North Carolina using claims data from 2000–2002.

RESULTS. The 3 high-intensity practices all made numerous changes to care processes. Most of the 17 low-intensity practices reported changes in their gastroenteritis care processes. Gastroenteritis admission rates declined 45% in high-intensity practices and 44% in low-intensity practices during the study compared with 11% in the control practices.

CONCLUSIONS. A practice-based, multimodal quality improvement intervention that targets multiple care processes on the basis of evidence-based guidelines lowered rates of gastroenteritis hospitalization in a Medicaid network. This approach could lower costs attributable to gastroenteritis for Medicaid programs.

Key Words: quality improvement • gastroenteritis

Abbreviations: ORT—oral rehydration therapy • AAP—American Academy of Pediatrics • QI—quality improvement • ORS—oral rehydration salts

Acute gastroenteritis is one of the most common and costly diseases among children in the United States. Each year there are ~37 million cases of acute diarrhea among children <5 years old, resulting in nearly 4 million physician visits, 220000 hospitalizations, and ~300 preventable deaths.1,2 The annual direct cost of care for these children is estimated to be >2 billion dollars.3,4

Evidence shows that gastroenteritis care needs improvement. The substantial geographic variation in hospitalizations for gastroenteritis suggests many hospital stays are avoidable.5,6 A recent study of childhood admissions for dehydration suggests the majority of hospitalized children could be treated in an alternative setting, such as a physician's office.7 The average cost of a gastroenteritis hospitalization is estimated to be >$2000.7

One promising strategy to improve care for gastroenteritis is increasing the appropriate use of oral rehydration therapy (ORT). ORT has many advantages over intravenous therapy, including lower cost and application in diverse settings (including a patient's home). In outpatient settings where intravenous therapy is not readily available, the decision to treat with intravenous therapy may necessitate hospitalization. ORT use in emergency departments is equivalent to intravenous therapy in improving dehydration at 2 hours, is initiated more quickly, and may decrease resultant hospitalization.8 Despite evidence-based recommendations from the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention, ORT is underused by US physicians.9–14 Practice-level barriers, such as the need for additional staff training and staff/physician attitudes about the inconvenience of ORT in office settings, primarily determine whether physicians routinely use ORT.11–13

Improving the quality of health care in US practices for acute clinical conditions has been challenging.15,16 Research addressing practice-based quality improvement (QI) has shown mixed results. Educational outreach visits by clinical content experts to practices has shown potential in affecting change.17–19 Peers or "local experts" were also shown to influence physician behavior more readily than traditional continuing medical education or professional society guidelines.20–22 However, multimodal strategies are more likely to be successful in changing clinical practice than single-faceted interventions.23 The purpose of this study was to examine the effect of a practice-based, multimodal QI intervention on hospital admission rates for gastroenteritis. We hypothesized that an intervention promoting evidence-based gastroenteritis guidelines that used a multimodal approach in a Medicaid managed care network could lower admission rates attributable to gastroenteritis for children.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Study Design and Participants
Twenty pediatric practices (all members of AccessCare, Inc, a not-for-profit Medicaid managed care network in North Carolina) that served 73000 Medicaid-enrolled children participated in the study. At the time of this study, the AccessCare network included pediatric practices serving the largest number of Medicaid enrollees in North Carolina. The target patient population was children <5 years old in these practices. The intervention purpose was to improve the quality and reduce the cost associated with the care of gastroenteritis for children covered by Medicaid in the AccessCare network. A secondary goal was to demonstrate the effectiveness of the intervention. We implemented the project in 2 stages. Three intervention practices were chosen to participate in a high-intensity intervention, and the remaining 17 intervention practices received a lower-intensity intervention that included learning from the practice-based development by the high-intensity practices. All practices participating in AccessCare were included in the intervention program. AccessCare leadership and project faculty selected the 3 high-intensity practices on the basis of the following criteria: (1) had a physician leader willing to participate; (2) represented medium to high rates of gastroenteritis hospitalization (as required by the network, to maximize the potential impact on network costs); and (3) represented each of 3 geographic regions in North Carolina (west, central, and east). The first 3 eligible practices contacted agreed to participate in the 6-month long high-intensity phase.

Intervention
The AccessCare network created a faculty group that included clinical experts in gastroenteritis, QI experts, and network leaders. Beginning in 2001, the network provided all 20 practices with a series of educational sessions based on evidence-based guidelines from the Centers of Disease Control and Prevention and AAP and practical aspects of ORT, a patient education video on ORT for use in waiting rooms (developed specifically for the AccessCare patient population), performance feedback on oral rehydration salts (ORS) use and admission rates for gastroenteritis, and free ORS (Pedialyte; Ross, Columbus, OH]) and generic ORS salts (World Health Organization) to distribute to patients or to use for ORT in the practice (for all patients, not solely Medicaid patients). In addition, practice-based care managers (predominantly registered nurses employed by the network) in all practices attended an educational session on ORT administration techniques and parent education delivered by project nursing faculty (Ms Edwards and Ms Powell). The application of QI strategies was not part of this baseline intervention.

In addition, the high-intensity practices participated in a 6-month long intervention from March 2001 to September 2001, which included: (1) application of multiple QI strategies (process mapping and analysis [documenting, discussing, and changing care processes]; rapid, small scale tests of changes [plan-do-study-act cycles]; and local control of improvement planning by interdisciplinary practice teams),7 and (2) collaboration between project faculty and practice improvement teams, as well as collaboration between teams. Project faculty provided: (1) education about applications of evidence-based guidelines; (2) coaching in process improvement; and (3) examples of clinical tools and prompts. The infrastructure for these interactions included: (1) a site visit by project faculty to lead the process-mapping exercise; (2) monthly conference calls for all 3 practices focusing on a clinical or process improvement topic, as well as sharing practice progress; and (3) monthly follow-up calls to each practice from project faculty (Drs Johnson and Randolph) to address practice-specific issues. Each high-intensity practice formed a "gastroenteritis improvement team" (including ≥1 physician, nurse, and administrative staff member). Practice improvement teams selected all changes to test and implement, as well as the sequence of changes.

After the 6-month intervention, the low-intensity practices participated in a conference call with the "gastroenteritis improvement teams" from the high-intensity practices in December 2001. The discussion was led by the high-intensity practices and facilitated by project faculty (Drs Randolph, Johnson, and Wegner and Ms Powell). The discussion focused on the successes and lessons learned in the high-intensity practices, as well as describing the use of a number of practice-based tools developed to assist with office implementation. These tools included color-coded diagrams to outline office flow for gastroenteritis patients, dehydration assessment, patient education information, and ORT instructions for clinicians and parents (tools can be found at: www.cincinnatichildrens.org/svc/alpha/h/health-quality/programs/topics/gastroenteritis.htm).

The study protocol was approved by the University of North Carolina Committee on the Protection of Rights of Human Subjects.

Outcome Measures and Data Collection
The main outcome for this study was change in the annual rate of gastroenteritis hospital admissions per 1000 Medicaid children <5 years old. We used North Carolina Medicaid claims data for calendar years 2000 to 2002 to determine each practice's gastroenteritis admission rates. Based on previous research and feedback from coders in several network practices, we used 35 International Classification of Diseases, Ninth Edition, codes to identify hospital admissions attributable to gastroenteritis (as the primary diagnosis).7 Four codes (008.61 [rotavirus], 008.8 [viral gastroenteritis], 276.5 [dehydration], and 558.9 [gastroenteritis NOS]) represented 95% of gastroenteritis admissions identified. Annual practice admissions for gastroenteritis were divided by each practice's average monthly enrollment of Medicaid children <5 years of age and multiplied by 1000 to determine admission rates. We also assessed whether high-intensity practices could make multiple process changes in their practices that were consistent with evidence-based guidelines. Process changes were documented by project staff during conference calls and by a follow-up survey after the intervention. Finally, we assessed the level of adoption of changes in the low-intensity practices using a survey of practice care managers in 2002. This survey asked practices whether they (1) had a gastroenteritis improvement team, (2) used the tools developed by high-intensity practices, and 3) were using ORT in their office.

We obtained practice characteristics, such as location and the number of Medicaid children served, from AccessCare network data. The proportion of practices with in-office intravenous therapy available at baseline (1999) was derived from an AccessCare survey of all practice care mangers in 2002. The use of ORS was measured by inventory assessments during the study.

Statistical Analysis
We used a controlled, before/after study design to compare the change in gastroenteritis hospital admission rates separately in the high- and low-intensity intervention practices and practices caring for all other Medicaid recipients in North Carolina that are not in a managed care network (control practices) by using Medicaid claims data for calendar years 2000 (preintervention) to 2002. Inferential statistics were not used because these data represent the entire Medicaid population <5 years of age from 2000 to 2002 (and thus were not a sample). Thus, no P values are reported for this outcome.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Intervention practices differed substantially from control practices in baseline rates of gastroenteritis admissions, Medicaid enrollees, and practice specialty (Table 1). In 2000, high-intensity practices had 6.6 admissions per 1000 enrollees, low intensity-practices had 3.2 admissions per 1000 enrollees, and control practices had 12.2 admissions per 1000 enrollees. The control practices represented a broad range of specialties (nearly half are family or general practices, 17% were pediatric practices). In addition, control practices served a smaller number of Medicaid enrollees; an average of 3464 and 3831 in the intervention practices versus an average of 365 in the control practices. Only 41% of low-intensity practices reported providing in-office intravenous therapy in 1999. High-intensity practices all reported providing in-office intravenous therapy at baseline, although in follow-up interviews with these practices, we learned that intravenous therapy was not routinely provided.


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  		TABLE 1 Practice Characteristics at Study Baseline (2000)

 
All 3 high-intensity practices successfully made numerous changes to their system of care for gastroenteritis. As anticipated, the process changes varied by practice because each team adapted strategies to their unique setting. These changes can be summarized as follows: (1) creating a system to identify patients with gastroenteritis symptoms at registration with immediate triage to a nurse to assess for dehydration; (2) creating a protocol to administer (usually by a parent with nurse supervision) and monitor ORT by using small frequent doses consistent with AAP guidelines (5 mL/min dosing initially); (3) identifying an "ORT nurse" to train other clinical staff about ORT; (4) creating a system to reliably distribute free ORS at gastroenteritis acute visits; (5) using printed educational materials to augment verbal teaching by physicians and nursing staff; (6) updating gastroenteritis telephone advice; and (7) collaborating with local emergency departments to increase use of ORT in emergency department settings. All 3 high-intensity practices reported regular in-office ORT during the intervention period. Before the intervention, none of the practices routinely provided ORT. The average estimated amount of ORT used by the high-intensity practices was 52 L compared with 18 L by the low-intensity practices during the 6 months of the second phase of the intervention.

The 17 low-intensity practices were surveyed near the end of the study period in 2002. Forty-one percent of practices reported having a gastroenteritis improvement team, and 50% reported using ≥1 tool developed by high-intensity practices. Most of those not using the tools reported that they were using ORT in their office. Respondents reported that the most helpful tools were those for documentation, treatment, parent education, information on getting started, and case studies from the high-intensity practices.

All 20 intervention practices had large declines in gastroenteritis admissions during the study period (Fig 1). The high-intensity practices had an admission rate of 6.6 per 1000 in 2000. By 2002, the high-intensity practices had reduced their gastroenteritis admission rate to 3.6 per 1000, a 45% reduction. The low-intensity practices started with lower rates of admission (because of study selection criteria). In 2000, rates were 3.2 per 1000; by 2002, they had decreased to 1.8 per 1000, a 44% reduction. Control practices had admission rates of 12.2 per 1000 in 2000 and declined slightly to 10.9 per 1000 in 2002 (11% reduction).


Figure 1
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  		FIGURE 1 Comparison of change in admission rates for gastroenteritis from baseline (year 1) to postintervention (year 3) between intervention and control practices.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
A practice-based, multimodal QI intervention that targeted multiple care processes reduced gastroenteritis hospitalizations for children <5 years old enrolled in Medicaid. The relative reduction in gastroenteritis hospitalizations was similar for both the low- and high-intensity interventions.

To our knowledge, only 1 study has assessed the effectiveness of an intervention addressing practice barriers to effective gastroenteritis care in primary care practices. Duggan and colleagues24 demonstrated that a simple intervention in community practices (giving free ORS with instructions to parents at acute diarrhea visits) could reduce gastroenteritis-related health care use. However, because systematic reviews and recent randomized, controlled trials of interventions to change physician practice here demonstrated that multimodal approaches are more effective than focused approaches, we used a multimodal approach.19,25,26

Practice-based QI interventions have demonstrated mixed success. In a recent systematic review, Shortell and colleagues27 reported that QI interventions were more likely to be successful if they (1) involved a nucleus of physicians, (2) provided specific feedback, and (3) provided a supportive organization structure.27 Several recent trials have shown success in QI implementation in practice-based settings for chronic conditions and preventive care. Common themes in successful programs include local implementation under flexible conditions consistent with typical practice environments and the use of small-scale tests of change to frequently reinforce practice success.28–30 The current study adds to this literature in demonstrating the success of a QI intervention capitalizing on similar components applied to an acute condition.

We attribute the success of the intervention to several key features, which may be important for effective QI initiatives in primary care practices. The intervention was the practice-based, multimodal effort, not the specific changes implemented (the result of this intervention). Any attempt to replicate this intervention should focus on the practice-based, multimodal design (eg, peer-to-peer teaching) rather than on the exact changes made by the practices. Giving control to those intimately involved in a system's processes is a long-standing QI principle with proven success.28,31,32 Most of the specific changes implemented in our study originated from practice teams, not from project faculty. Other key design features included collaboration between faculty experts and practices, peer-to-peer teaching, sharing of evidence-based tools developed locally, provision of resources (eg, patient education videos and ORS) by network leadership, performance feedback, and principles of academic detailing.18,20,33

Academic detailing, the use of clinical expert outreach visits to physician practices, has been repeatedly shown to improve provider knowledge. A recent meta-analysis showed positive effects on practices in all studies reviewed. The change in gastroenteritis admissions by the low-intensity practices was surprising because this intervention was more limited and admission rates were already low. In fact, gastroenteritis admission rates declined by 28% before the peer-to-peer conference calls and an additional 22% after peer-to-peer teaching. This demonstrates the significant success of this less intensive intervention. Although it is possible that the high-intensity intervention did not have any additional effect, we speculate that the impact of the peer-to-peer teaching and tools provided by the high-intensity practices may have helped the low-intensity practices achieve similar results and improve sustainability. By sharing lessons learned, the high-intensity practices reinforced their own improvements and the representatives served as opinion leaders. Physicians and their practices are more likely to adopt new strategies after learning of the proven success of their peers.21,34 The use of local opinion leaders as peer teachers in QI interventions has shown mixed success.

Our study has several limitations. Data collected for this study were aggregate practice-level data rather than patient-level data. Such data are best used for addressing plausibility of a hypothesis or hypothesis generation rather than assessing causality.35 For example, we do not know whether patients admitted for gastroenteritis received ORT. Future studies including patient-level data would strengthen the causal link between this intervention and reduced hospitalizations. Also, we did not collect data on adverse events in this project, because the primary purpose was for QI, and the intervention was based on established evidence-based guidelines. Intervention practices differed from control practices in their Medicaid population size, specialty mix, and baseline admission rates. Differences is specialty practice patterns, staffing, local hospitals, and Medicaid population or practice size may explain the differences between baseline intervention and control practice admission rates. The current study cannot control for these differences. Future studies should attempt to include a more comparable control group. Also, unequal distribution of gastroenteritis outbreaks may have affected the results. We are unaware of any such factors. Among the control practices, a temporal decline in gastroenteritis admissions was observed. This may be because of secular improvements in practice patterns, financial incentives to keep patients out of the hospital, or because of declines in gastroenteritis severity during the study years. However, the relative reduction in admissions was small in the control group compared with the reductions in the intervention practices. Finally, because of the selection of intervention practices, this study may not be generalizable to smaller practices, patients not covered by Medicaid, or family medicine, general practice, or multi-specialty practices.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
A practice-based, multimodal QI intervention seemed to be effective in reducing hospitalizations attributable to gastroenteritis in a North Carolina Medicaid managed care network. Because gastroenteritis is one of the most common and costly pediatric illnesses, this type of intervention could yield substantial cost savings for other Medicaid programs. For the intervention practices in this study, the improvements resulted in 53 fewer Medicaid-covered admissions for gastroenteritis in 2002 (14 in high-intensity practices and 39 in low intensity practices). This translates into roughly $106 000 cost savings per year for this 20-practice network. This is a conservative estimate in that it does not include patients not enrolled in Medicaid (who likely benefited from the intervention) and it does not include emergency department use.

To date, QI interventions have largely been applied to chronic conditions or preventive services. Our study offers an example of a QI intervention to improve care for gastroenteritis and could serve as a model to improve care of other acute care conditions in primary care practices.


   ACKNOWLEDGMENTS
 
This study was supported by AccessCare, Inc, and the National Research Service Awards Training Program of the US Health Resources and Services Administration (grants 5 T32 PE 14001–12 and T32 HP 14001–17).

We thank the creative and dedicated physicians, nurses, and staff who participated in the high-intensity intervention from Kinston Pediatric Associates, Mountain View Pediatrics, and Sandhills Pediatrics. In particular, we thank improvement team members Shantel Carter, Susan Freeman, Orville Reece, MD, and Candace Smith (Kinston Pediatric Associates); Julie Causby, Christi Ferraro, Melissa Jones, Karen Lail, Rudy Medina, MD, John Whalley, MD, Terri Rhyder, and Connie Williams (Mountain View Pediatrics); and Anna Carpenter, Debbie Cruse, Elaine Hines, Amy Ivey, Cate Mason, MD, Jean McClendon, Beth O'Connor, Paulette Royal, Cindy Shamburger, Jamie Smith, and William Stewart, MD (Sandhills Pediatrics). We also thank Marcelletta Miles, RN, BSN, from the AccessCare, Inc, network for vision and leadership. In addition, we thank Julius Goepp, MD, and Larry Nazarian, MD, for sharing their clinical knowledge and invaluable experiences during the project. Finally, we are indebted to Clay Bordley, MD, MPH, and Peter Margolis, MD, PhD, for insightful comments to improve this manuscript.


   FOOTNOTES
 
Accepted Jan 31, 2007.

Address correspondence to Adam J. Zolotor, MD, MPH, University of North Carolina, Department of Family Medicine, CB#7595, Chapel Hill, NC 27599-7595. E-mail: ajzolo{at}med.unc.edu

Preliminary results from this study were presented as a platform presentation at the Ambulatory Pediatrics Association meeting; May 4, 2002; Baltimore, MD.

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Glass RI, Lew JF, Gangarosa RE, LeBaron CW, Ho MS. Estimates of morbidity and mortality rates for diarrheal diseases in American children. J Pediatr. 1991;118 :S27 –S33[CrossRef][ISI][Medline]
  2. Kilgore PE, Holman RC, Clarke MJ, Glass RI. Trends of diarrheal disease-associated mortality in US children, 1968 through 1991. JAMA. 1995;274 :1143 –1148[Abstract]
  3. Avendano P, Matson DO, Long J, Whitney S, Matson CC, Pickering LK. Costs associated with office visits for diarrhea in infants and toddlers. Pediatr Infect Dis J. 1993;12 :897 –902[ISI][Medline]
  4. Matson DO, Estes MK. Impact of rotavirus infection at a large pediatric hospital. J Infect Dis. 1990;162 :598 –604[ISI][Medline]
  5. To T, Feldman W, Young W, Maloney SL. Hospitalization rates of children with gastroenteritis in Ontario. Can J Public Health. 1996;87 :62 –65[ISI][Medline]
  6. Connell FA, Day RW, LoGerfo JP. Hospitalization of Medicaid children: analysis of small area variations in admission rates. Am J Public Health. 1981;71 :606 –613[Abstract/Free Full Text]
  7. McConnochie KM, Conners GP, Lu E, Wilson C. How commonly are children hospitalized for dehydration eligible for care in alternative settings? Arch Pediatr Adolesc Med. 1999;153 :1233 –1241[Abstract/Free Full Text]
  8. Spandorfer PR, Alessandrini EA, Joffe MD, Localio R, Shaw KN. Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial. Pediatrics. 2005;115 :295 –301[Abstract/Free Full Text]
  9. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Practice parameter: the management of acute gastroenteritis in young children. Pediatrics. 1996;97 :424 –435[Abstract/Free Full Text]
  10. Duggan C, Santosham M, Glass RI. The management of acute diarrhea in children: oral rehydration, maintenance, and nutritional therapy. Centers for Disease Control and Prevention. MMWR Recomm Rep. 1992;41(RR-16) :1 –20
  11. Reis EC, Goepp JG, Katz S, Santosham M. Barriers to use of oral rehydration therapy. Pediatrics. 1994;93 :708 –711[Abstract/Free Full Text]
  12. Nazarian LF. A synopsis of the American Academy of Pediatrics' practice parameter on the management of acute gastroenteritis in young children. Pediatr Rev. 1997;18 :221 –223[Free Full Text]
  13. Bezerra JA, Stathos TH, Duncan B, Gaines JA, Udall JN Jr. Treatment of infants with acute diarrhea: what's recommended and what's practiced. Pediatrics. 1992;90 :1 –4[Abstract/Free Full Text]
  14. Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16) :1 –16
  15. Langley GJ. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass; 1996
  16. McLaughlin CP, Kaluzny A, eds. Continuous Quality Improvement in Health Care. 2nd ed. Gaithersburg, MD: Aspen; 1999
  17. Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2000;(2) :CD000409
  18. Wong RY, Lee PE. Teaching physicians geriatric principles: a randomized control trial on academic detailing plus printed materials versus printed materials only. J Gerontol A Biol Sci Med Sci. 2004;59 :1036 –1040[ISI][Medline]
  19. Funk M, Wutzke S, Kaner E, et al. A multicountry controlled trial of strategies to promote dissemination and implementation of brief alcohol intervention in primary health care: findings of a World Health Organization collaborative study. J Stud Alcohol. 2005;66 :379 –388[ISI][Medline]
  20. Adsit R, Fraser D, Redmond L, Smith S, Fiore M. Changing clinical practice, helping people quit: the Wisconsin Cessation Outreach model. WMJ. 2005;104(4) :32 –36
  21. Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E, Singer J. Opinion leaders vs audit and feedback to implement practice guidelines: delivery after previous cesarean section. JAMA. 1991;265 :2202 –2207[Abstract]
  22. Oldenburg B, Guy SP. Diffusion of innovations. In: Glanz K, Rimer BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Research, and Practice. 3rd ed. San Francisco, CA: Jossey-Bass; 2002:312–334
  23. Verstappen WH, van der Weijden T, Dubois WI, et al. Improving test ordering in primary care: the added value of a small-group quality improvement strategy compared with classic feedback only. Ann Fam Med. 2004;2 :569 –575[Abstract/Free Full Text]
  24. Duggan C, Lasche J, McCarty M, et al. Oral rehydration solution for acute diarrhea prevents subsequent unscheduled follow-up visits. Pediatrics. 1999;104(3) . Available at: www.pediatrics.org/cgi/content/full/104/3/e29
  25. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Getting research findings into practice: closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ. 1998;317 :465 –468[Free Full Text]
  26. Asarnow JR, Jaycox LH, Duan N, et al. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial. JAMA. 2005;293 :311 –319[Abstract/Free Full Text]
  27. Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 1998;76 :510 , 593–624
  28. Margolis PA, Lannon CM, Stuart JM, Fried BJ, Keyes-Elstein L, Moore DE Jr. Practice-based education to improve delivery systems for prevention in primary care: randomised trial. BMJ. 2004;328 :388[Abstract/Free Full Text]
  29. Schoenbaum M, Unutzer J, Sherbourne C, et al. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. JAMA. 2001;286 :1325 –1330[Abstract/Free Full Text]
  30. Rosenthal MS, Lannon CM, Stuart JM, Brown L, Miller WC, Margolis PA. A randomized trial of practice-based education to improve delivery systems for anticipatory guidance. Arch Pediatr Adolesc Med. 2005;159 :456 –463[Abstract/Free Full Text]
  31. Hulscher GK, Wensing M, Grol RP, van der Weijden T, van Weel C. Interventions to improve the delivery of preventive services in primary care. Am J Public Health. 1999;89 :737 –746[Abstract/Free Full Text]
  32. Berwick DM. Disseminating innovations in health care. JAMA. 2003;289 :1969 –1975[Abstract/Free Full Text]
  33. Albert DA, Anluwalia KP, Ward A, Sadowsky D. The use of "academic detailing" to promote tobacco-use cessation counseling in dental offices. J Am Dent Assoc. 2004;135 :1700 –1706[Abstract/Free Full Text]
  34. Rogers EM. Diffucion of Innovations. 4th ed. New York, NY: Free Press; 1995
  35. Hulley SB. Designing Clinical Research: An Epidemiologic Approach. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics




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