Qualitative Evaluation to Explain Success of Multifaceted Technology-Driven Hypertension Intervention
PCDC in the News, Journal of Managed Care, December 20, 2011
Authors: Mari Millery, PhD; Donna Shelley, MD, MPH; Daren Wu, MD; Pamela Ferrari, RN; Tuo-Yen Tseng, MA; and Helene Kopal, MPA, MPH
Hypertension affects one-third of the American adult population.
Appropriate management of hypertension presents a significant
opportunity to improve cardiovascular health outcomes through
interventions in primary care settings. The costs of healthcare,
medication, and missed days of work from hypertensionrelated symptoms
and complications were $76.6 billion in 2010. Improved
control of blood pressure among those diagnosed with hypertension would
pay off in lowered incidence of stroke and heart disease.
Health information technologies (HITs) are a promising tool for improving quality of care in primary care settings, including underserved settings such as community health centers (CHCs). Much of HIT research tests the efficacy of isolated technology components, such as a decision support tool or computerized order entry. Less is known about the effectiveness of HIT-based interventions in community-based settings that combine multiple intervention components in a comprehensive effort to improve quality-of-care outcomes. Evidence of effectiveness of HIT to improve hypertension outcomes is mixed.
Effective interventions to improve community health outcomes call for complex multi-level and multi-component approaches. However, it is challenging to design studies that can attribute quantitative health outcomes to particular intervention components. Instead, the outcomes indicate success of the entire “package.” Process evaluation is an avenue to explore questions about the effective “ingredients” of such interventions. One important purpose of process evaluation is to explain the results of an outcome evaluation, also called “interpretive evaluation.” Process evaluation using qualitative methods may be particularly wellsuited for understanding why a complex intervention led to its outcomes.
In the domain of information technology (IT) implementation, several models posit factors that explain success of IT. The Technology Acceptance Model (TAM) builds on general social-behavioral theories and proposes constructs such as perceived usefulness and perceived ease of use as predictors of end-user acceptance and use of IT. The DeLone & McLean Information System Success Model predicts organizational and individual impact of IT systems from system use, user satisfaction, system quality, and information quality. A third model proposed by Ovretveit et al identifies factors that help or hinder HIT implementation, including characteristics of the HIT system, the implementation process, leadership, resources, and organization culture and climate. These models are helpful in categorizing and labeling factors of importance in HIT implementation research.
This qualitative study examined a multi-component quality improvement (QI) intervention in a CHC with several practice sites in New York that included clinical decision support within an electronic health record (EHR) and provider feedback. The intervention had a positive impact on provider adherence to hypertension guidelines and hypertension control among patients. The goal of the qualitative analysis was to explain how different facets of the multi-component intervention contributed to the positive impact of improved hypertension control.
