Background and Resources

Evaluation Background

High blood pressure, or hypertension, is a leading risk factor for cardiovascular disease (CVD), but only about half of people with high blood pressure have the condition under control.¹ The integration of primary care and public health approaches is a key strategy for preventing and treating high blood pressure and CVD. Activities resulting from the integration of public health and primary care can include use of health information technology, data-driven quality improvement, and implementation of evidence-based models such as patient-centered medical homes (PCMHs).² A complementary strategy to improve control of high blood pressure through quality improvement activities is the use of learning collaboratives to integrate primary care and public health efforts.³

In the fall of 2014, the Division for Heart Disease and Stroke Prevention (DHDSP) sought to identify state health departments that were implementing promising strategies for reducing the impact of CVD on population-level health outcomes. DHDSP selected the Maryland Department of Health and Mental Hygiene’s (MDHMH) Center for Chronic Disease Prevention and Control (CCDPC) and its partner, the Maryland Learning Collaborative (MLC), to participate in a 15-month Enhanced Evaluability Assessment (EEA).⁴ The EEA is an expedited evaluation that aims to show program effectiveness, build practice-based evidence, and disseminate actionable findings in a relatively short time frame.

CDC conducted a mixed-methods EEA to evaluate program processes and outcomes resulting from implementation of the MLC and the mutually beneficial partnership with the CCDPC. The evaluation used qualitative and quantitative data collection methods to assess program implementation, outcomes, and contextual factors that influenced the intervention. Document review and in-depth group interviews were the main data sources for assessing program implementation, while secondary data analysis of CVD clinical quality measures was the main data source for assessing outcomes.

The evaluation sought to learn from a state-based learning collaborative model that was intended to drive quality improvement in primary care practices in the state of Maryland. As a result, CDC identified a few key program strategies that may be replicable in other state-based contexts to improve quality of care delivery for cardiovascular and chronic disease.

Program Background

The MLC exemplified a public health–clinical partnership that leveraged a learning collaborative model and quality improvement (QI) activities, aiming to improve clinical quality of care and CVD-related outcomes. The MLC is a statewide learning collaborative that was created to support primary care practices participating in a pilot to facilitate implementation of the patient-centered medical home (PCMH) model. The MLC played a key role in supporting CVD and hypertension-focused health system quality improvement activities with 52 primary care practices by providing technical assistance, training, and support and working collaboratively with practices to optimize and enhance data collection, management and reporting processes. DHDSP partnered with the CCDPC and the MLC to assess CVD clinical quality measures within primary care practices in the collaborative. The objective of the DHDSP evaluation was to assess changes in CVD risk factors and related quality-of-care indicators that align with DHDSP’s focus on improving risk factors for CVD and other chronic disease outcomes.

Through the evaluation, CDC identified key outcomes that demonstrated the reach and potential impact of the Maryland collaborative model on health care practices and patient-level outcomes.

• Through its partnership with the MLC, the CCDPC was able to reach 52 primary care practices that served more than 132,000 insured patients across 17 counties.
• The MLC measured practice-level performance on CVD quality measures between 2011 and 2014. Some of these measures tracked the progress practices made toward reaching targets for prescribing aspirin when appropriate (National Quality Foundation [NQF] measure 0067), controlling high blood pressure (NQF measure 0018), cholesterol management (NQF measure 0075), and smoking cessation (NQF measure 0028b).
• From 2011 to 2014, participating practices demonstrated significant improvements toward measuring patients’ blood pressure (NQF measure 0013), assessing patients’ tobacco use (NQF measure 0028a), and recommending tobacco cessation interventions (NQF measure 0028b).
• A total of 10,349 patients whose hypertension was previously uncontrolled achieved blood pressure control across 44 of the partnering clinics from 2011 to 2014.

For additional information on the Maryland Learning Collaborative, please see the program Field Notes [PDF-507K] and Evaluation Summary [PDF-477K].

Additional Resources

There are a variety of evaluation tools and resources to assist health departments with their evaluation efforts on the DHDSP website. Below is a selection of relevant tools and resources.

Field Notes

Field Notes are documents that highlight examples of different evaluation approaches at the state, local, and community levels.

• DC Million Hearts Program [PDF-3.4M]
• Maryland Learning Collaborative [PDF-507K]

Evaluation Summary

CDC identifies programs that show promise for preventing heart disease and stroke. Evaluation summaries briefly describe a program’s evaluation process, including methods and key findings.

• Maryland Learning Collaborative [PDF-477K]

Coffee Breaks

Coffee Breaks are 20-minute mini-trainings focused on knowledge translation tools and evaluation basics for chronic disease programs.

• Evaluating Quality Improvement Interventions [PDF-1.4M]
• Evaluating Community-Clinical Linkages [PDF-1.4M]
• Evaluating Quality Improvement Initiatives — An Example of a High Blood Pressure Clinical QI Intervention [PDF-4.4M]
• Tools for Partnership Evaluation [PDF-4.3M]

Evaluation Basics

Evaluation Basics are evaluation technical assistance tools that clarify approaches to and methods of evaluation, provide examples, and recommend resources for additional reading.

• Fundamentals of Evaluating Partnerships [PDF-9.2M]

References

1. Merai R, Siegel C, Rakotz M, Basch P, Wright J, Wong B, et al. CDC grand rounds: a public health approach to detect and control hypertension. MMWR Morb Mortal Wkly Rep. 2016;65:1261–1264.
2. Institute of Medicine. Primary care and public health: exploring integration to improve population health. Washington (DC): National Academies Press; 2012.
3. Jarris PE, Moffatt SG, Romero EW, Sellers K. Million Hearts, three levers. J Public Health Manag Pract. 2014;20(2):264–266.
4. Losby JL, Vaughan M, Davis R, Tucker-Brown A. Arriving at results efficiently: using the enhanced evaluability approach. Prev Chronic Dis. 2015;12:150413.

Learn more about forming powerful program partnerships from the DC Million Hearts Program’s Recipe for Public Health.