BACKGROUND Disseminating care guidelines into clinical practice remains challenging, partly due to inadequate evidence on how best to help clinics incorporate new guidelines into routine care. This is particularly true in safety net community health centers (CHCs). METHODS This pragmatic comparative effectiveness trial used a parallel mixed methods design. Twenty-nine CHC clinics were randomized to receive increasingly intensive implementation support (implementation toolkit (arm 1); toolkit + in-person training + training webinars (arm 2); toolkit + training + webinars + offered practice facilitation (arm 3)) targeting uptake of electronic health record (EHR) tools focused on guideline-concordant cardioprotective prescribing for patients with diabetes. Outcomes were compared across study arms, to test whether increased support yielded additive improvements, and with 137 non-study CHCs that share the same EHR as the study clinics. Quantitative data from the CHCs' EHR were used to compare the magnitude of change in guideline-concordant ACE/ARB and statin prescribing, using adjusted Poisson regressions. Qualitative data collected using diverse methods (e.g., interviews, observations) identified factors influencing the quantitative outcomes. RESULTS Outcomes at CHCs receiving higher-intensity support did not improve in an additive pattern. ACE/ARB prescribing did not improve in any CHC group. Statin prescribing improved overall and was significantly greater only in the arm 1 and arm 2 CHCs compared with the non-study CHCs. Factors influencing the finding of no additive impact included: aspects of the EHR tools that reduced their utility, barriers to providing the intended implementation support, and study design elements, e.g., inability to adapt the provided support. Factors influencing overall improvements in statin outcomes likely included a secular trend in awareness of statin prescribing guidelines, selection bias where motivated clinics volunteered for the study, and study participation focusing clinic staff on the targeted outcomes. CONCLUSIONS Efforts to implement care guidelines should: ensure adaptability when providing implementation support and conduct formative evaluations to determine the optimal form of such support for a given clinic; consider how study data collection influences adoption; and consider barriers to clinics' ability to use/accept implementation support as planned. More research is needed on supporting change implementation in under-resourced settings like CHCs. TRIAL REGISTRATION ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

中文翻译：

---

增强的实施支持是否可以改善社区诊所的指南一致护理？混合方法的结果，务实的比较有效性试验。

背景技术将护理指南传播到临床实践中仍然具有挑战性，部分原因是关于如何最好地帮助临床将新指南纳入常规护理的证据不足。在安全网社区卫生中心（CHC）中尤其如此。方法该实用的比较有效性试验采用平行混合方法设计。随机分配了29个CHC诊所以接受越来越密集的实施支持（实施工具包（第1组）；工具包+现场培训+培训网络研讨会（第2组）；工具包+培训+网络研讨会+提供的实践促进（第3组））采纳电子健康记录（EHR）工具，该工具侧重于针对糖尿病患者的符合指南的心脏保护处方。比较了各个研究部门的结果，来测试增加的支持是否能带来额外的改善，并使用137个非研究性CHC与研究诊所共享相同的EHR。使用调整后的Poisson回归，使用来自CHC的EHR的定量数据比较指南一致的ACE / ARB和他汀类药物处方的变化幅度。使用多种方法（例如访谈，观察）收集的定性数据确定了影响定量结果的因素。结果接受更高强度支持的CHC的结果并未以加性方式得到改善。ACE / ARB处方在任何CHC组中均未改善。他汀类药物的处方总体改善，与非研究型CHC相比，仅在第1组和第2组CHC中显着增加。影响发现无累加影响的因素包括：EHR工具的各个方面，减少了其实用性，提供预期的实施支持的障碍以及研究设计元素（例如，无法适应所提供的支持）。影响他汀类药物疗效总体改善的因素可能包括：人们对他汀类药物处方指南的认识出现长期趋势，在有动机的诊所自愿参与研究的情况下存在选择偏见，以及使诊所工作人员专注于目标结果的研究参与。结论实施护理指南的工作应：在提供实施支持时确保适应性，并进行形成性评估，以确定针对特定诊所的此类支持的最佳形式；考虑研究数据收集如何影响采用；并考虑阻碍诊所按计划使用/接受实施支持的能力的障碍。需要更多的研究来支持资源贫乏地区（如CHC）中的变更实施。试验注册ClinicalTrials.gov，NCT02325531。2014年12月15日注册。