• Deborah J Cohen, Tamar Wyte-Lake, Pamela Bonsu, Stephanie L Albert, Lorraine Kwok, Margaret M Paul, Ann M Nguyen, Carolyn A Berry, and Donna R Shelley.
• From Department of Family Medicine, Oregon Health & Science University, Portland, OR (DJC, TWL); Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, North Hills, CA (TWL); Department of Population Health, New York University Grossman School of Medicine, New York, NY (SLA, LK, MMP, CAB); Center for State Health Policy, Rutgers University, New Brunswick, NJ (AMN); School of Global Public Health, New York University, New York, NY (DRS). cohendj@ohsu.edu.
• J Am Board Fam Med. 2022 Sep 16.

BackgroundGuidelines for managing and preventing chronic disease tend to be well-known. Yet, translation of this evidence into practice is inconsistent. We identify a combination of factors that are connected to guideline concordant delivery of evidence-informed chronic disease care in primary care.MethodsCross-sectional observational study; purposively selected 22 practices to vary on size, ownership and geographic location, using National Quality Forum metrics to ensure practices had a ≥ 70% quality level for at least 2 of the following: aspirin use in high-risk individuals, blood pressure control, cholesterol and diabetes management. Interviewed 2 professionals (eg, medical director, practice manager) per practice (n = 44) to understand staffing and clinical operations. Analyzed data using an iterative and inductive approach.ResultsCommunity Health Centers (CHCs) employed interdisciplinary clinical teams that included a variety of professionals as compared with hospital-health systems (HHS) and clinician-owned practices. Despite this difference, practice members consistently reported a number of functions that may be connected to clinical chronic care quality, including: having engaged leadership; a culture of teamwork; engaging in team-based care; using data to inform quality improvement; empaneling patients; and managing the care of patient panels, with a focus on continuity and comprehensiveness, as well as having a commitment to the community.ConclusionsThere are mutable organizational attributes connected-guideline concordant chronic disease care in primary care. Research and policy reform are needed to promote and study how to achieve widespread adoption of these functions and organizational attributes that may be central to achieving equity and improving chronic disease prevention.© Copyright by the American Board of Family Medicine.

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