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Author Notes:

Correspondence: Steven D Culler; sculler@emory.edu

Authors' Contributions: MLP conceived and developed the study, drafted the study protocol, and leads the implementation.

JAP, PHN and SDC helped to draft both the study protocol and this manuscript.

RLR coordinates the ongoing study, collected pilot data, and helped to draft the manuscript.

NHA and RFP are members of the Study Steering Group, and have contributed to the development of the protocol.

All authors read and approved the final manuscript.

Disclosures: The author(s) declare that they have no competing interests.


Research Funding:

This study, is funded by a grant from the National Institute of Diabetes, Digestive and Kidney Disorders. (R18 DK 075692), follows the CONSORT guidelines, and is registered per ICMJE guidelines: Clinical Trial Registration Number: NCT00482768.

A group randomized trial of a complexity-based organizational intervention to improve risk factors for diabetes complications in primary care settings: study protocol


Journal Title:

Implementation Science


Volume 3, Number 15


Type of Work:

Article | Final Publisher PDF


Background Most patients with type 2 diabetes have suboptimal control of their glucose, blood pressure (BP), and lipids – three risk factors for diabetes complications. Although the chronic care model (CCM) provides a roadmap for improving these outcomes, developing theoretically sound implementation strategies that will work across diverse primary care settings has been challenging. One explanation for this difficulty may be that most strategies do not account for the complex adaptive system (CAS) characteristics of the primary care setting. A CAS is comprised of individuals who can learn, interconnect, self-organize, and interact with their environment in a way that demonstrates non-linear dynamic behavior. One implementation strategy that may be used to leverage these properties is practice facilitation (PF). PF creates time for learning and reflection by members of the team in each clinic, improves their communication, and promotes an individualized approach to implement a strategy to improve patient outcomes. Specific objectives The specific objectives of this protocol are to: evaluate the effectiveness and sustainability of PF to improve risk factor control in patients with type 2 diabetes across a variety of primary care settings; assess the implementation of the CCM in response to the intervention; examine the relationship between communication within the practice team and the implementation of the CCM; and determine the cost of the intervention both from the perspective of the organization conducting the PF intervention and from the perspective of the primary care practice. Intervention The study will be a group randomized trial conducted in 40 primary care clinics. Data will be collected on all clinics, with 60 patients in each clinic, using a multi-method assessment process at baseline, 12, and 24 months. The intervention, PF, will consist of a series of practice improvement team meetings led by trained facilitators over 12 months. Primary hypotheses will be tested with 12-month outcome data. Sustainability of the intervention will be tested using 24 month data. Insights gained will be included in a delayed intervention conducted in control practices and evaluated in a pre-post design. Primary and secondary outcomes To test hypotheses, the unit of randomization will be the clinic. The unit of analysis will be the repeated measure of each risk factor for each patient, nested within the clinic. The repeated measure of glycosylated hemoglobin A1c will be the primary outcome, with BP and Low Density Lipoprotein (LDL) cholesterol as secondary outcomes. To study change in risk factor level, a hierarchical or random effect model will be used to account for the nesting of repeated measurement of risk factor within patients and patients within clinics. This protocol follows the CONSORT guidelines and is registered per ICMJE guidelines:

Copyright information:

© 2008 Parchman et al; licensee BioMed Central Ltd.

This is an Open Access work distributed under the terms of the Creative Commons Attribution 2.0 Generic License (http://creativecommons.org/licenses/by/2.0/).

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