Outreach in Primary Care

William Hogg, M.D.C.M., F.C.F.P. (corresponding author)
Professor and Director of Research
The Department of Family Medicine,
University of Ottawa, Canada
whogg@uottawa.ca
Neill Baskerville, B.A. Hons., M.H.A.
Ph.D. Candidate
Department of Health Studies and Gerontology
University of Waterloo
nbbasker@ahsmail.uwaterloo.ca
Chris Peterson, Ph.D.
Honorary Visiting fellow
School of Social Sciences
La Trobe University,
Melbourne.
c.peterson@latroeb.edu.au
Enrique Soto, Ph.D.
Research Manager
Department of Family Medicine
University of Ottawa, Canada
esoto@uottawa.ca
Carmel M. Martin, MBBS, MSc, PhD
Associate Professor of Family Medicine
Northern Ontario School of Medicine, Canada
Adjunct Professor
Indigenous Peoples' Health Research Centre
First Nations University of Canada
Carmel.Martin@NorMed.ca
Jacques Lemelin, M.D., F.C.F.P.
Associate Professor
Department of Family Medicine
University of Ottawa, Canada
jlemelin@uottawa.ca

Abstract

Background: There is wide recognition about the need for applying an evidence-based approach to improve the delivery of preventive services in primary care. However, evidence-based guidelines are not widely adopted despite the fact that a number of tools and interventions have been used to narrow this uptake gap.
Discussion: A review of the literature on the results from interventions designed to improve service delivery in primary care suggests that while the existing evidence is still very limited to determine what works best and why, there are also some discernible trends on the subject: 1. Multiple interventions tend to be more effective than single ones; 2. Approaches that ‘tailor’ or adapt tools and interventions to the needs and characteristics of the deployment context tend to be more effective compared to those that do not; 3. Changes in practice behavior are difficult to promote without a system’s approach for understanding that behavior; 4. The use of facilitators for improving preventive services has a positive effect on improving delivery of preventive services. The authors define and present the Outreach Facilitation Model (OFM), deemed as a promising due to its flexibility for combining multiple tools, tailoring, a systems approach and facilitation towards changing practice behavior.
Summary: Because clinical guidelines to ensure the delivery of proper preventive care are not self-implementing, there is always room for improvement of services’ delivery in this health care area. The examination of evidence from research on strategies for achieving such improvement is not conclusive but reveals that some of them tend to show effectiveness. Their articulation and adaptation under the outreach facilitation model has shown positive results, it is worth continue exploring and seems to be a promising tool for improving the quality of service delivery.

I. Background
Improvement in compliance with appropriate preventive measures could have an important influence on the health of Canadians. A reduction in the ordering of inappropriate tests has the potential to save money. As providers of first contact and continuing care, family physicians are ideally suited to deliver preventive services. Indeed, the College of Family Physicians of Canada states in its educational objectives that “the physician shall practice a systematic approach to the prevention of illness”.(Awde et al., 1981) Family physicians as a group reach a large percentage of the population (over 70 percent of Canadians visit a physician at least once a year) and when delivering even moderately effective interventions have great potential for impacting overall population health.(Abrams et al., 1997) There has recently been the recognition by the Canadian government of the need for physician, practice and health system change with an organizational approach.(2004)
Internationally, there is recognition and a drive to reshape primary care with an emphasis around health promotion, disease and injury prevention and chronic disease management.(Marriott & Mable, 2000) Prevention and evidence-based guidelines are all supported by major international health and professional bodies in light of increasing proof of the importance of an evidence-based approach to chronic disease and health promotion activities. There is also growing realization of a rapid rise in chronic non-communicable diseases that currently account for some 60% of global deaths and almost half (47%) of the global burden of disease.(World Health Organization, 2005) The WHO accepts the need to strengthen and rationalize an evidence-based approach to chronic disease and health promotion activities in light of the following factors: the growing social and economic burden of chronic diseases; the existing knowledge base; the gap in implementation; and the demand for increased support. As noted by Leininger and coworkers, ‘more than ever before, patients, providers, payers, and policy makers are interested in including preventive services in comprehensive health insurance benefits packages, emphasizing the importance these services hold for improving the health of the country…Achievement of preventive health goals is often used as a measure of quality by insurers and other monitoring groups’(1996; p 108). McGinnis (1988) has also argued that clinical prevention fits very well into an overall approach of improving the health of the population, pointing out that the change from acute to chronic and degenerative disease has been the impetus behind the need to develop more effective preventive services.

In primary care, prevention efforts need to reflect the complete practice profile of diseases encountered by general practitioners in their routine work. However, most studies cited in the literature, focus only on cancer prevention (Dietrich et al., 1992; Manfredi et al., 1998; Kinsinger, Harris, Qaqish, Strecher, & Kaluzny, 1998) or only on cardiovascular disease prevention.(Hulscher et al., 1997; Kottke et al., 1992; Aubin, Vezina, Fortin, & Bernard, 1994) A truly effective approach will allow an improvement in all the different preventive maneuvers that are within the scope of the family physician’s practice. Ideally, the approach to improving prevention will be integrated into illness care, since an estimated 81% of a family physician’s practice is comprised of acute (58%) and chronic (24%) patient health problems.(Stange et al., 1998)

Despite the prevalent view favoring a systematic integration of preventive care into primary care, there does not seem to be a simple answer for how to best accomplish this.(Oxman, Thomson, Davis, & Haynes, 1995) Several reviews have focused on methods of implementing guidelines and improving quality of care.(Buntinx, Winkens, Grol, & Knottnerus, 1993; Grimshaw & Russell, 1993; Davis, Thomson, Oxman, & Haynes, 1995; Tamblyn & Battista, 1993) However, while there is evidence from the literature that can guide a group of practicing physicians on how to organize themselves to practice preventive medicine effectively, very few medical practices currently implement these strategies.(Leininger et al., 1996)

This paper argues that outreach facilitation is a promising useful tool that can contribute towards closing that implementation gap. The review of literature presented here on efforts for improving service delivery in primary care, suggests that guideline uptake is more likely when multiple interventions are implemented, when they are adapted to the characteristics and context of the practices involved, and when they address uptake barriers within an office systems approach. It is unlikely that all barriers working against the integration and proper implementation of prevention in primary care may be overcome by the use of a single albeit multifaceted strategy. However, outreach facilitation seems to hold promise because it is flexible enough to be adapted to promote the use of different evidence based guidelines in diverse primary care practice settings, to promote the use of various tools and technologies, and to introduce evaluation practices and office organization systems for eliciting practice change.

II. Discussion
1. Evidence-Based Guidelines: Widely Promoted but Not Widely Adopted
The Canadian Task Force of Preventive Medicine has lead (Canadian Task Force on Preventive Health Care, 2004) in Canada with preventive care guidelines for primary care. The Ontario Guidelines Advisory Committee (GAC) (Guidelines Advisory Committee, 2004) is empowered by the Ministry of Health and Long-Term Care and the Ontario Medical Association to provide evidence-based health care in Ontario, and encourage physicians to use the best available clinical practice guidelines. Policy makers recognize the need to implement guidelines of evidence-based medicine prevention and health promotion.
The provision of appropriate preventive care services to patients by primary care physicians has been addressed widely in the literature, but many patients still do not receive appropriate screening. Despite the impact of the Cochrane Collaboration and the commitment in family medicine and primary care in many countries to embrace an evidence based approach for practice, there are a number of areas where physicians are aware of the need for best practice approaches, yet these have not been systematically implemented. By the same token, despite the considerable amount of money spent on clinical research and the development of preventive guidelines, relatively little attention has been paid to ensuring that these guidelines be implemented in family practice routine.(Bero et al., 1998)

Although there is widespread acceptance of these recommended guidelines by the medical profession, the proportion of patients who are not up to date with the recommended preventive measures remains high.(Hutchison, Woodward, Norman, Abelson, & Brown, 1998; Lewis, 1988; Battista, 1983; Battista, Palmer, Marchand, & Spitzer, 1985; Smith & Herbert, 1993; Rosser, McDowell, & Newell, 1991; McDowell, Newell, & Rosser, 1989; Ornstein, Garr, Jenkins, Rust, & Arnon, 1991; Satenstein, Lemelin, Folkerson C, Scott K, & Hogg, 1991; Carney, Dietrich, Freeman, & Mott, 1993; Jaen, Crabtree, Zyzanski, Goodwin, & Stange, 1998; Humair & Ward, 1998; McAlister, Teo, & Laupacis, 1997; Love et al., 1993; Kottke, Solberg, Brekke, Cabrera, & Marquez, 1997) For instance, Love et al (1993) indicate in their study on the frequency of screening for breast cancer in primary care group practices in non-metropolitan areas in the Midwest (USA), that half of the women (50.2%) in their study did not have a mammography in at least 2 years of the three-year study period. Similarly, in a survey of internists and family physicians on the management of isolated systolic hypertension, only 58% of the family physicians reported recommending Thiazide diuretics as first line therapy.(McAlister, Teo, & Laupacis, 1997) In addition, actual levels of screening have been shown to be low in both practices and the community.(Rosser, McDowell, & Newell, 1991) In fact only 12-19% of patients over 65 years of age had vaccinations for influenza, and fewer than 30% of women had appropriate screening for cervical cancer.(Rosser, McDowell, & Newell, 1991)
There are many reasons why medical practices are unable or unwilling to implement the proven strategies that foster the provision of preventive care (Frame, 1992; Belcher, Berg, & Inui, 1988; Hutchison, Abelson, Woodward, & Norman, 1996; Burack, 1989; Cabana et al., 1999), including the difficulty of implementing widespread practice change, problems associated with getting front line commitment to evidence based practices that may not support traditional and culturally specific clinical practices in some regions, and problems associated with knowledge transfer. Similarly, it is difficult to implement effective evaluations to measure the extent of practice according to best practice knowledge. Hutchinson and coworkers (1996) identified a set of barriers from a survey of family physicians and general practitioners in south-central Ontario, revealing three types of related obstacles working against proper delivery of preventive care: a) Patient refusal to or lack of interest and compliance with preventive care recommendations; b) absence of effective reminder systems to increase patient attendance to preventive care appointments; and c) priority given to the presenting problem brought by the patient.
Frame (1992) outlines and classifies some of the barriers to providing effective preventive services (system, patient and physician barriers) while maintaining that they can largely be overcome by physicians improving their skills, time management and practice organization. However, a prescriptive approach such as this needs to be tempered with a better understanding of the culture and pressures of the local and provincial environments within which physicians work.

2. What can be done to increase the use EBGs in preventive care?
Various interventions have been tried to overcome obstacles to implement better preventive care. Bero and coworkers(1998) found in a systematic review of 18 selected literature reviews certain common themes in improvements through interventions. That is, computer decision support systems –including computerized reminders- improved doctors’ performance, educational outreach visits were beneficial regarding prescribing decisions, and multiple interventions appeared to be more effective than single interventions. They also noted, however, that none of the reviews addressed the cost effectiveness of interventions. Further they found a number of methodological difficulties associated with literature reviews. That is they generally failed to identify criteria for selecting articles; they did not avoid bias; and did not report criteria that were used to assess validity.
Oxman et al (1995) reviewed 102 trials which focused on one or more interventions aimed at improving health professionals’ performance. These included the use of educational materials, conferences, outreach visits, academic detailing (Soumerai & Avorn, 1990), local opinion leaders, patient-mediated interventions and local consensus approaches. They argue that ‘interventions to improve professional performance are complex, and any cogent interpretation of the results of these trials requires a disentangling of the variation in the characteristics of the targeted professionals, the interventions studied, the targeted behaviors and the study designs (Oxman, Thomson, Davis, & Haynes, 1995) (p. 1425). Nonetheless some interventions are available that if used effectively could improve practice care delivery, based on the best evidence available. In addition, they point out that ‘closer collaboration of researchers in the area of health professional performance, health services and quality assurance appears to be both desirable and necessary’(Oxman, Thomson, Davis, & Haynes, 1995; p. 1427). There is also little evidence of the long-term effects of interventions on practice outcomes.(Stange, Goodwin, Zyzanski, & Dietrich, 2003)

Frame (1992) recommends a number of guidelines for preventive programs’ improvement. These include that the program must be relatively easy and include procedures only that are considered worthwhile; an organized recording system needs to be used; reinforcements and checks need to be used; and adequate time needs to be given for prevention services.

2a. Single vs. Multiple Interventions
There is evidence that single interventions in family practice achieve only modest improvements in preventive care and eventually reach a ceiling at which no further gains in improvement can be achieved without altering the intervention approach.(Oxman, Thomson, Davis, & Haynes, 1995; Davis, Thomson, Oxman, & Haynes, 1995; Hulscher, Wensing, Grol, van, & van, 1999; Lomas & Haynes, 1988; Wensing & Grol, 1994; Wensing, van, & Grol, 1998) Oxman and his colleagues found that although many single interventions have modest or negligible practical effects when used alone, when coupled or combined with other intervention strategies the effects may be cumulative and significant in changing physician behavior and improving health outcomes.(Oxman, Thomson, Davis, & Haynes, 1995; Davis, Thomson, Oxman, & Haynes, 1995) Hulscher et al (2001) confirmed that it is difficult to predict the effect of a single intervention on prevention outcomes, and that multifaceted interventions tend to be more effective.

Margolis and coworkers (2004) combined an educational program with improvements in office systems and found that increased delivery rates of delivering preventive care services to children resulted. Similar to Oxman, Wensing et al (Wensing & Grol, 1994; Wensing, van, & Grol, 1998) reviewed 61 randomized controlled trials. The interventions were classified into information transfer, information linked to performance, learning through social influence, and management support. They found that information transfer alone was only effective in 11% of studies, whereas combinations of information transfer and learning through social influence or management support were effective in 50% and 43% of studies respectively. Information linked to performance was effective in 67% of studies, and 83% of studies involving a combination of three or more interventions were effective.(Wensing & Grol, 1994) However, intervention effectiveness varies considerably and there is no theoretical base to explain why certain types of interventions work better than others.(Wensing, van, & Grol, 1998)

The research into multifaceted approaches for improving preventive care performance has demonstrated that an organized system consisting of a model or framework as well as appropriate sets of tools can increase preventive care that is delivered in a busy primary care practice.(Leininger et al., 1996; Dietrich et al., 1992; Manfredi et al., 1998; Hulscher et al., 1997; Ornstein, Garr, Jenkins, Rust, & Arnon, 1991; Carney, Dietrich, Keller, Landgraf, & O'Connor, 1992; Dietrich, Woodruff, & Carney, 1994; McVea et al., 1996; Palmer et al., 1996) An example is the work of Carney et al (1992), where they provide evidence of how the use of an “office system” intervention can be successfully adopted by primary care providers to improve cancer prevention. In their study all the practices randomly assigned to the intervention group succeeded in adopting at least one of the office system tools (flow sheets); and between a third and three quarters of the practices also adopted other intervention tools (patient education materials, prevention posters, health maintenance diaries, prevention prescription pads, etc.). Further, a recently convened panel of experts in clinical guideline implementation has concluded that guideline implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organization, and the external environment.(Solberg et al., 2000) Programs that stress physician knowledge alone, such as traditional CME and dissemination of guidelines, are insufficient to change practice behavior.(Grimshaw & Russell, 1993; Davis, Thomson, Oxman, & Haynes, 1995; Tamblyn & Battista, 1993) Single interventions are less likely to result in significant improvement of practice behavior as compared to interventions that attend to many guideline adoption factors and that use two or more strategies in an intensive combined intervention (Oxman, Thomson, Davis, & Haynes, 1995; Davis, Thomson, Oxman, & Haynes, 1995; Lomas & Haynes, 1988; Wensing & Grol, 1994; Wensing, van, & Grol, 1998; Solberg et al., 2000) which is consistent with the findings from Bero et al(Bero et al., 1998) referred to earlier. Thompson’s et al (2000) Cochrane review of 13 studies on the effect of educational outreach visits on professional practice concludes that visits are effective, particularly when combined with social marketing, while pointing out that the cost-effectiveness of the visits has not been properly evaluated.

2b. Tailored Interventions
McGinnis(1988) has noted the complex interrelationships among different independent, intervening and constraining variables to clinical prevention. These variables in combination make it difficult to achieve improvements in clinical preventive performance. Further, given the diversity of practice environments it is unlikely that "one size fits all" approaches to improving preventive care will ever be able to address the needs of all providers and their patients.(Stange, 1996)
Stange (2003) and coworkers found that there is evidence that an approach based on practice-individualisation can result in beneficial effects of interventions after one year. In their report on the study they attribute the sustainability of the intervention effect partly to the practice individualized approach during the intervention. For them, the tailoring of tools and approaches to the practices’ unique motivations, structures and processes makes their adoption and institutionalization much more likely.

The value of tailoring change strategies in other clinical contexts and to specific aspects of service delivery, specific health conditions or to patients is also regarded positively by other researchers. For instance, Glasgow et al (2004) consider that behavior change principles identified for individuals can also be applied at the clinic level to produce patient behaviour change, and that for those changes to crystallize it is central to customize change plans to meet the needs of the office setting: “Just as tailoring to an individual’s risk, preferences and social environment enhance success at the individual level, customizing how a practice will implement the 5A’s [change model] is critical” (p. 94).
Following this line of thought, a randomized trial is being conducted “…to evaluate the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.”(Fretheim, Oxman, Treweek, & Bjorndal, 1927) (p 1). Although the results from this trial have not been published yet, results from another study focusing on a person-level tailored intervention to increase mammography screening rates reported a significant effect and its sustainability at 12 and 24 months after intervention.(Rimer et al., 2002)
2c. Systems, Delivery of Preventive Care Services and Office Change
Recently there has emerged an understanding that doctors’ offices are complex systems which require internal organizational change of practices’ operation.(Margolis et al., 2004) However, there has been little research on how best to implement organizational change in primary care with a system of mainly individual practices with a range of different characteristics and needs.(Cohen et al., 2004) There is little evidence of research in this area, although the United Kingdom National Health Service Trusts and the Australian Divisions of General Practice are mandated to provide implementation support for preventive care and other activities, and the Australian divisions have widely implemented outreach facilitation service models in many best practice areas.(Australian Government: Department of Health & Ageing, 2004) In the United States the Agency for Healthcare Research and Quality (AHRQ) supports health systems work in general. The AHRQ(Agency for Healthcare Research and Quality (AHRQ)., 2000) states that there is information indicating that applying a system, defined as “…a process that integrates staff roles, responsibilities, and tools for the routine delivery of preventive care”(Frame, 2000), increases the delivery of preventive services in clinical settings. Leininger and coworkers (1996) argue that one of the main reasons why preventive services are not used as frequently as they should be is due to a lack of organized and systemic approaches in practices.

Several efforts have emerged to conceptualize and guide system implementation and change at the practice level. Cohen et al (2004) developed a practice change model from a quality improvement intervention that was successful in improving the use of preventive maneuvers. They found that key ingredients of success included motivating key stakeholders to change; having resources for change that were personal, interactive and instrumental; having the community and healthcare environment as motivators; and providing opportunities for change. Elwyn and Hocking (2000) found that it wasn’t possible to introduce professional and practice plans in publicly funded systems without focusing on management structures and educational plans, the basis for providing support for introducing changes. Grol and Grimshaw (1999) maintain that implementing quality improvements in family medicine is a slow process, and that evidence-based implementation approaches should be used. McBride and coworkers(McBride et al., 2000) maintain that improving prevention services is complex and requires further investigation. In recent reviews of quality improvement literature and of methods for disseminating and implementing evidence-based care Grimshaw and coworkers (Grimshaw et al., 2004; Grimshaw & Eccles, 1915) and Shojania and Grimshaw (2005) conclude that quality improvement approaches still need a theoretical foundation to understand provider and organizational change and guide the choice of specific interventions.

Miller et al (1998) recommend complexity theory as a way of implementing change in family medicine. They argue that practices are complex systems made up of physicians, office staff and patients who generate income, undertake organizational operations and deliver patient care. According to Miller and coworkers, joining, as well as transforming and learning are required to change practice characteristics and the behavior of practitioners.

2. c.1 System elements.
The understanding of a system as a process in the primary care context is also frequently associated to system tools or activities (interventions) that are known to enhance preventive practices. Examples of such tools and interventions include prenatal records, infant growth charts, checklists for well baby care and periodic health examinations, audit and feedback, and paper-based and computerized reminder and patient recall systems.(Buntinx, Winkens, Grol, & Knottnerus, 1993; Palmer et al., 1996; Buntinx et al., 1993; Winkens et al., 1995; Tierney, Hui, & McDonald, 1986; McDonald & Tierney, 1986; Frame, 1990; McPhee, Bird, Jenkins, & Fordham, 1989; Frame, Zimmer, Werth, & Martens, 1991; Harris, O'Malley, Fletcher, & Knight, 1990; Rudnick, Sackett, Hirst, & Holmes, 1977; Ravet, 1988; Hutchison, 1989; Steven & Douglas, 1986; Burack et al., 1998; Dickinson, 1989)
The efficiency of the various tools and preventive activities does vary and the reasons related to the variation are multiple. For instance, patient-mediated activities such as simple posters and brochures in patient waiting rooms have been shown to be effective for initiating smoking cessation (Cohen, Stookey, Katz, Drook, & Smith, 1989; Cummings et al., 1989) but ineffective in increasing delivery of other preventive measures.(Mead, Rhyne, Wiese, Lambert, & Skipper, 1995; Williams, Boles, & Johnson, 1998) Giving patients their own medical record is an additional and not entirely new strategy that has been shown to have no effect.(Drury et al., 2000) Collecting dissatisfaction data through questionnaires from patients attending preventive care activities of general practitioners have apparently increased the performance of those activities.(Steven & Douglas, 1986) Due to computer-generated reminders to providers, the rate of influenza immunization among seniors significantly increased by 165%, growing from 10.1% to 26.8%.(Hutchison, 1989) Palmer et al (1996) found in a randomized controlled trial that providing feedback to providers on their actual performance stimulated greater quality improvement than knowing guidelines and discussing review criteria. In the trial, practitioners were notified of experimental guidelines, had criteria discussed in accordance with the guidelines, and were provided with performance feedback. Significant improvements occurred after performance feedback was given, but not after the first two stages. Because reminder systems are a system tool that has attracted much attention, we look at it in more detail below.

2. c.2 Reminder Systems
Most educational approaches or organizational systems to improve preventive performance require the patient to initiate a visit to the doctor. Not all patients do this. In fact, the patients most at risk for some illnesses and most likely to benefit from the screening or procedure are the least likely to attend the doctor.(Harris, O'Malley, Fletcher, & Knight, 1990; Kleinman & Kopstein, 1981; Fidler, Boyes, & Worth, 1968; Anonymous1984) Outgoing or active recall systems are required to reach these patients. There is ample evidence of the effectiveness of active recall systems.(Rosser, McDowell, & Newell, 1991; McDowell, Newell, & Rosser, 1989; Ornstein, Garr, Jenkins, Rust, & Arnon, 1991; Clementz, Aldag, Gladfelter, Barclay, & Brooks, 1990; McDowell, Newell, & Rosser, 1986; Rosser, Hutchison, McDowell, & Newell, 1992; Whiting-O'Keefe, Simborg, Epstein, & Warger, 1985; Shroff et al., 1988; Robertson et al., 1989; Bass, 1985; Hogg, 1990; Frame, 1995; Hogg, Bass, Calonge, Crouch, & Satenstein, 1998) Yet recall systems have not been widely adopted(Abelson & Lomas, 1990; Audunnson, 1986) as part of the basic preventive infrastructure in Canadian practices.

As with other tools, the effectiveness of reminder systems varies depending on factors such as reminder type (active, computerized, manual, etc.) and practice characteristics. Harris et al (1990) studied the impact of different reminders systems (no reminder, manual and computerized) on the performance of seven preventive procedures (two types of immunizations, four cancer screening tests and tonometry for glaucoma). They found that preventive performance improved for all procedures regardless of the type of reminder system, but the increase was significantly higher (53%) for computerized reminders systems compared to manual system (43%). They also identified that the improvement in performance varied depending on the procedure, ranging from a 47% increase to no change, pointing out to the complexity of factors influencing preventive maneuvers.
Tierney and coworkers (1986) reported from their randomized controlled trial that having immediate reminders increased physician compliance with preventive care protocols more so than delayed feedback. Frame (1990) argued that computerized systems for generating reminders are available to large groups, but currently unavailable for smaller groups. Hence generating appropriate reminder systems that are simple, not time consuming or expensive and that have the correct data can be problematic for some practices. Frame (1991) further maintains that many computerized tracking systems are inappropriate for small practices for the following reasons: they are linked to large data system and are therefore quite expensive; data entry is slow; health maintenance data information is usually limited in content and application; and physician reminders are created only for patients with an appointment. In another study, McDowell (1989) found that in encouraging cervical screening in family practice, reminders that were issued by a physician produced a more effective screening compliance than either the physician being issued with the names of those ready for screening, or by a reminder phone call being made by the practice nurse.

2d. Facilitation: A Multifaceted Approach
Multifaceted approaches using facilitation to improve prevention in primary care have been used in the United Kingdom in which specially trained nurses known as facilitators organized preventive care in "busy" practitioner's offices using approaches such as academic detailing, chart audit and feedback for the prevention and early detection of cardiovascular disease.(Fowler, Fullard, & Gray, 1992; Fullard, Fowler, & Gray, 1987) Dietrich et al have found that the health facilitator model was efficacious in establishing office routines for providing needed preventive services and significantly improved provision of early cancer detection and preventive services.(1992) The study randomized practices into a 2x2 factorial design to receive one, two or none of the interventions, which were education to physicians and assistance from a facilitator to establish routines for providing cancer early detection and prevention services (system intervention). Whereas education was associated with the increase of only one preventive procedure (mammogram) of the 10 included in the study, the system intervention was associated with increases on six preventive procedures (mammography, recommendation for breast self-examination, clinical breast examination, faecal occult blood testing, advice to quit smoking, and the recommendation to decrease dietary fat).(Dietrich et al., 1992)
Hulscher et al have found that adapting the facilitator intervention to the practice and combining several effective methods is an important determinant of success.(1997) Other randomized controlled trials have also shown outreach facilitation to be successful in improving delivery of preventive services.(Manfredi et al., 1998; Cockburn et al., 1992) For example, Kottke and coworkers (1992) found in a randomized control trial of an intervention to encourage physicians to intervene in their patients’ smoking, that the intervention had successful outcomes. Since the introduction of training and support to organize a no smoking program, practices that used the program reported significant increases in patients reporting being asked if they smoked, being asked not to smoke, and being commended on ceasing if they gave up smoking, by their physician. Through their randomized trial for comparing three approaches to introduce smoking cessation programs to general practitioners in Australia, Cockburn et al (1992) report results in line with those from Kottke and coworkers: Physicians who received the intervention through personal delivery and a presentation by an educational facilitator with a follow up visit, were significantly more likely to have seen, understood and used the quit smoking intervention kit, compared to those physicians who received the kit through another person or through mail and had a phone call or mailed note as follow-up.

More recently, Lemelin, Hogg and coworkers (2001) have demonstrated the efficacy of the outreach facilitator intervention approach in providing management support to improve preventive care performance in a sample of Ontario Health Service Organizations (HSOs). Results show that the intervention group practices (n=22) significantly improved preventive performance by 36% over an 18 month period as compared to the control group (n=23) which showed no improvement in preventive performance.(Lemelin, Hogg, & Baskerville, 2001) The mean differences in preventive performance over time as measured by the index of eight recommended and five not recommended preventive maneuvers by chart audit were 11.32 for the intervention group and 0 (no difference) for the control group (p < .001).(Lemelin, Hogg, & Baskerville, 2001) Physicians involved in this study reported overall satisfaction ratings of 4.5 out of 5 with visits by a prevention facilitator once every two to three weeks and 90% indicated that they would participate in such an intervention again if given the opportunity.(Baskerville, Hogg, & Lemelin, 2001) This research has also involved the study of the cost savings associated to outreach facilitation.(Hogg, Baskerville, & Lemelin, 1909)

Research into Sustainability of Effect:
It is unknown how long the intervention effect from a multifaceted facilitator intervention for improving clinical preventive care lasts. McCowan et al (1997) conducted a study to examine the long-term effect of an intervention by an audit facilitator on the management of children with asthma in the U.K. It was found that although the effect of the facilitator was significant, the effect lasted only for the period of the intervention. In contrast, Dietrich et al (1994) found that some improvements in early detection of cancer performance were maintained one year after the completion of an office system intervention which significantly affected cancer screening performance. Hogg et al also found evidence of long term sustainability in their facilitation trial.(2002) Determining the long-term sustainability of a facilitator intervention effect remains important for health policy decision-making.

Identification of the particular stage within the overall adoption process which best characterizes the practice and then tailoring the specific interventions to the requirements of that stage has been proposed as important in supporting practice changes and in attaining more successful outcomes in preventive service performance.(Cohen, Halvorson, & Gosselink, 1994; Main, Cohen, & DiClemente, 1995) Unfortunately, very few practices have the skill sets needed to carry out the process of change and quality improvement necessary to improve preventive performance.(Dietrich, Woodruff, & Carney, 1994; Winkens et al., 1995)

3. The Outreach Facilitation Model: What is it? Why does it make sense?
To facilitate means to make easier. Facilitation, according to the Oxford Dictionary (1984), is defined as “Assisting the progress of moving forward, making easy, smoothing the path of and speeding up the process”. At the center of both definitions rests the notion of providing support for a process to progress. In the general context of group work and dynamics, Bentley (1994) expands and sharpens this notion when stating that facilitation is the provision of opportunity resources, encouragement and support for a group to succeed in achieving its own objectives by enabling the group to take control and responsibility for the way they proceed. The three salient elements of Bentley’s perspective are a) the clear indication of the need of various resources (opportunity, encouragement, support), b) the need for a group’s clarity (and ideally commonly agreed-upon and thus resulting ownership) of its objectives, and c) the resulting control and responsibility of the group over the process.

Based on the previous definitions, on the literature reviewed here, on ten years of research and implementation work on facilitation applied to primary health services, we advance a model of outreach facilitation defined as follows:

The Outreach Facilitation Model (OFM) is a flexible, tailored, multifaceted, iterative support process, provided by an individual with a nursing degree and administration graduate degree external to the clinical setting, aimed at optimizing the operation of and results from individuals and groups delivering primary care services, by providing them with a) practice performance assessment, feedback, and consensus building towards goal setting and implementation, b) clinical, technical, organizational resources and practical advice, and c) encouragement to face and move through the challenges associated with practice change.

Discussing this definition helps to demonstrates why the OFM holds promise for improving service delivery in primary care. The notion of flexibility indicates that OFM can incorporate any of the existing tools to improve preventive care. The reference to tailoring brings to the fore the possibility and willingness of adapting the use of any such tools to the needs, preferences, circumstances and characteristics of the groups delivering services. Tightly related to flexibility is the concept of multiplicity (‘multifacetedness’). OFM is intended to support not only the use of any particular tool or resource, it supports the simultaneous deployment of various resources for improving service delivery, since service delivery is normally affected not by one but by several factors at the same time. The process is iterative in that the facilitator repeatedly and systematically visits and contacts doctors’ offices teams for gradually introducing practice change and monitoring its progress. Although practice assessment, feedback and consensus building are resources that fall under the category of technical resources, they are singled out because there is an explicit effort for applying planning and evaluation principles intended to yield sound information to orient and inform the change process and elicit practice buy-in. Finally, essential to OFM is the encouragement to the practice, provided through the personal and professional characteristics of the facilitator: knowledgeable of the primary care context and of doctors’ offices dynamics and systems; honest, empathic, reliable, flexible, positive and supportive of the skills being developed by the practice and of the confidence within the practice regarding the change process.

The OFM selects and combines elements from the quality improvement framework advanced by Leininger et al (1996) and from strategies designed to change practice patterns and improve preventive care identified by Oxman et al (1995) and by Wensing and Grol.(1994) The core components of the implementation process for OFM can be summarized as follows: 1. Individuals with bachelor’s degree in nursing, a graduate degree in administration and experience in facilitation are selected. 2. They undergo a training program that includes course work, assignments and practical experiences covering topics such as medical office computer systems, medical practice management, prevention in primary care, evidence-based medicine and facilitation and audit skills development. 3. They are assigned to about a dozen doctors’ offices (depending on practice size and distance from the facilitator’s location) to initiate the facilitation process. The frequency and period of time over which periodic visits take place depend on the characteristics and goals of the intervention. The length of each visit is determined by the doctor’s availability and meeting agenda. 4. Facilitators contact the practices and arrange appointments with the lead physician, other physicians and with practice staff when necessary to initiate the process. 5. Practices receive performance feedback based on the results from a miniaudit on the subject of interest. Physicians and staff with the aid of the facilitator use the feedback to identify their specific goals, performance levels and work plan for the intervention (goal setting and consensus building). 6. The practice and facilitator start the ongoing process of deploying and tailoring the appropriate tools and intervention strategies to implement the agreed-upon work plan. Facilitators also provide progress feedback and when necessary the practice may modify the work plan. 7. A second performance feedback takes place to detect and share the effects of the changes introduced by the practice.

The OFM is an intervention approach that makes sense; it incorporates key recommendations resulting from research on interventions for improving service delivery in primary care. The literature suggests that positive results in this area tend to spring from using multifaceted interventions, from focusing on organizational and systemic aspects of a practice’s operation and from adapting systems and tools to the practice’s reality. All these elements are present in OFM. Practices require more than guidelines and educational materials. The multifaceted approach of deploying facilitators into busy practices and providing management support is an intervention that holds promise for improving preventive care performance in diverse practice environments.

III. Summary
There is wide recognition about the need for applying an evidence-based approach to improve the delivery of preventive services in primary care. However, evidence-based guidelines are not widely adopted despite the fact that a number of tools and interventions have been used to narrow this uptake gap. A review of the literature on the results from interventions designed to improve service delivery in primary care suggests that while the existing evidence is still very limited to determine what works best and why, there are also some discernible trends on the subject: 1. Multiple interventions tend to be more effective than single ones; 2. Approaches that ‘tailor’ or adapt tools and interventions to the needs and characteristics of the deployment context tend to be more effective compared to those that do not; 3. Changes in practice behavior are difficult to promote without a system’s approach for understanding that behavior; 4. The use of facilitators for improving preventive services has a positive effect on improving delivery of preventive services. The authors define and present the Outreach Facilitation Model (OFM), deemed as a promising due to its flexibility for combining multiple tools, tailoring, a systems approach and facilitation towards changing practice behavior.

IV List of abbreviations used
AHRQ: United States the Agency for Healthcare Research and Quality
GAC: Ontario Guidelines Advisory Committee
HSOs: Ontario Health Service Organizations
OFM: Outreach Facilitation Model
V. Competing Interests
The authors declare that they do not have competing interests.
VI. Authors’ Contributions
The authors contributed to the article as follows: WH and JL conceived the study; WH, NB, CP, ES and CM contributed to the manuscript drafting and critically assessed its content.

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