Abstract / Summary
Abstract Background Practice facilitation (PF) is widely used to support implementation of evidence-based interventions in primary care, yet how PF improves implementation remains poorly specified. PF's influence may operate in part through changes in clinical practice and office systems, such as workflows, leadership support, and information systems, which shape the extent to which use of an evidence-based practice is expected, supported, and rewarded. Within the broader context of the STop UNhealthy Alcohol Use Now (STUN) trial, this analysis examined whether PF was associated with progress in implementing clinical and organizational change supporting alcohol screening and brief intervention. Methods Twenty-one small to medium primary care practices in North Carolina received 12 months of PF, including quality improvement coaching, electronic health record support, and structured implementation guidance, followed by 6 months of sustainment follow-up. Clinical practice and office systems changes were measured monthly with the Key Driver Implementation Scale (KDIS; range 0–45). Repeated-measures analysis of variance (RM-ANOVA) provided an overall test of change in KDIS over the facilitation phase, with paired-t contrasts comparing early intervention (Q1, months 1–3) to intervention midpoint (Q2) and to the end of facilitation (Q4). Mixed-effects growth models with quadratic time characterized trajectory shape across all 18 months. Results PF was associated with significant increases in KDIS scores across implementation periods (Q1 mean 20.41, Q2 mean 24.49, Q4 mean 25.04; p<.001). Growth modeling showed a non-linear pattern with steep early gains that decelerated over time (linear β = 1.52, p<.001; quadratic β=−0.06, p<.001) and predicted KDIS scores increasing by roughly 7 points over 18 months on the 0–45 scale. Higher baseline screening rate was associated with faster early gains that leveled off, whereas greater practice capacity for QI was associated with slower but more sustained gains through month 18. Conclusions PF was associated with measurable KDIS improvement that decelerated over the facilitation period and varied with baseline screening performance and operational QI capacity. The pace and durability of change, not endpoint alone, may inform PF dose, timing, and tailoring. Repeated measurement of these drivers may help advance research on PF’s relationship to clinical change. Trial registration: ClinicalTrials.gov NCT04317989. March 23, 2020 –registered, https://clinicaltrials.gov/study/NCT04317989