• Deborah J Cohen, Bijal A Balasubramanian, Stephan Lindner, William L Miller, Shannon M Sweeney, Jennifer D Hall, Rikki Ward, Miguel Marino, Rachel Springer, K John McConnell, Jennifer R Hemler, Sarah S Ono, David Ezekiel-Herrera, Andrea Baron, Benjamin F Crabtree, and Leif I Solberg.
• From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS). cohendj@ohsu.edu.
• J Am Board Fam Med. 2022 Sep 16.

IntroductionTo examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care.MethodsMixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach.ResultsCooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes.DiscussionLong-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.© Copyright by the American Board of Family Medicine.

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