Introduction
Policy, environmental, and systems-level interventions are part of a comprehensive approach to managing high blood pressure and high cholesterol, which are key risk factors for heart disease and stroke. In this qualitative case study, we identified clinical practices in health care organizations that used policy, environmental, or systems-level interventions to improve patient outcomes for these conditions. Our 4 objectives were to describe 1) policy, environmental, and systems-level interventions; 2) enabling factors and barriers that affected implementation; 3) methods for evaluating the success of the intervention; and 4) lessons learned from the health care practices that implemented these interventions.

Methods
Through literature review and expert guidance, we identified 34 health care practices that used policy, environmental, and systems-level interventions to manage high blood pressure and high cholesterol. In 2003, we conducted case study interviews with key informants for 9 health care practices that 1) demonstrated improved patient outcomes for blood pressure or cholesterol; 2) implemented the interventions for at least 1 year; and 3) remained committed to sustaining or institutionalizing interventions. We taped and transcribed the interviews and used Centers for Disease Control and Prevention EZ-Text software (www.cdc.gov/hiv/software/ez-text.htm) to code, categorize, and analyze the responses.

Results
The health care practices we studied implemented specialized lipid clinics, disease management programs, physician reminder systems, and participation in the Health Resources and Services Administration’s Bureau of Primary Care Health Disparities Collaboratives. All practices used comprehensive systems for patient care that were well-defined, measurable, and linked to desirable patient outcomes. Most relied on data systems to identify patients targeted for the interventions and practice areas that needed improvement, and to track the progress of patients and practitioners in meeting goals. Factors contributing to success included support for patient self-management, interventions integrated into the practice’s daily work flow to make implementation easier for staff, leadership and staff commitment, and community involvement.

Conclusion
Comprehensive policy, environmental, and systems-level interventions for patient care can be effective in controlling chronic conditions such as high blood pressure and high cholesterol.