Multiple Methods of Implementing Evidence Based Best Practices: Examples from QUERI Health Services Research & Development Service Department of Veterans Affairs Knowledge Utilization International Conference Quebec, Canada September 25, 2003 Quality Enhancement Research Initiative
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Multiple Methods of Implementing Evidence Based Best Practices: Examples from
QUERI
Health Services Research & Development ServiceDepartment of Veterans Affairs
Knowledge Utilization International ConferenceQuebec, Canada
September 25, 2003
Quality Enhancement Research Initiative
Overview
• Macro Context– Brief description of the Veterans Health Administration
and QUERI
• Evidence– The case for lipid management in ischemic heart
• Serve over 6.5 million veterans– Out of 26.5 million
veterans total in 2000 census
• Approximately 25% of all veterans use VHA
– VHA users are older, sicker, and poorer than veterans not using VHA
Benefits Package• Preventive services, including immunizations,
screening tests, and health education and training classes
• Primary health care • Diagnosis and treatment • Surgery, including outpatient surgery • Mental health and substance abuse treatment • Home health care • Respite (inpatient), hospice and palliative care • Urgent and limited emergency care • Drugs and pharmaceuticals
VHA Is Divided Into 21 VISNs
To enhance the quality and outcomes of VA health care by systematically translating or implementing evidence-based research findings into routine clinical practice
• Spinal Cord Injury (SCI)• Substance Use Disorder
(SUD)• Colorectal Cancer (CRC)
The Six-step QUERI Process
1. Identify high risk/high burden conditions
2. Identify best practices
3. Define existing practice patterns in VA and variations from best practices
4. Identify (or develop) and implement programs to promote best practices
5. Document patient outcomes and system improvements
6. Document improvements in health related quality of life
Clinical trials, guideline development
Ongoing evaluation and feedback
Small-scale demonstrations
New question
Outcomes studies
Pilot projects
Clinical research,
mainstream HSR
Implementation research
Implemen-tation policy
National Rollout
QUERI’s Research/Implementation Pipeline
Variations studies
Regional demonstrations
Program, tool development
Data, measures
Examples focus on lipid management for secondary prevention in patients
with ischemic heart disease
– Work started in 1999 and is on-going in 2003– Three inter-related projects
• First-round interventions 1999-2000• Follow up qualitative study 2001• Second-round electronic clinical reminder intervention
2002-2003 (Not described in this talk)
– Used PARIHS model as a heuristic to guide interventions
• Post-hoc in earlier projects, concurrent later
Evidence
• The beneficial effect of simvastatin in individual patients in 4S was determined mainly by the magnitude of the change in LDL-c (1).
• Each additional 1% reduction in LDL-c reduces MCE (IHD death and nonfatal MI) risk by 1.7% (1).
• Heart Protection Study: RCT with Simvastatin decreased mortality in a broad range of patients and reduced MI and stroke by one-third (2).
1. Simvastatin Survival Study Group. Lipoprotein changes and reduction in the incidence of major coronary heart disease events in the Scandinavian Simvastatin Survival Study (4S). Circ 97:1453-1460; 1998.
2. http://www.ctsu.ox.ac.uk/~hps/
Context: Round 1a
• Eight VA medical centers in a single VISN– VISN 20, Northwest Network– Wide variation in size
• Small, non-tertiary to large, tertiary, teaching
– Wide variation in number of IHD patients• 400 to 4000 per site
– Wide variation in number of primary care providers• 12 to 200
VHA Is Divided Into 21 VISNs
Facilitation: Round 1b
• Involvement in team selection• Trained team members
– Kick off meetings
• Offered menu of options for methods of intervening– Case management including pharmacist-led lipid clinics (3)– Point of care paper-based reminders (2)– Audit/feedback + patient education (1)– Complex, multi-faceted interventions (2)
• Teams selected their preferred method• Monthly follow up by project manager• Quarterly data extraction and reports
– Monitoring proportion of IHD patients with current LDL measurement, on treatment, and those at goal
Mean LDL for IHD Patients on Statins
96
98
100
102
104
106
108
Sep-
99
Oct
-99
Nov
-99
Dec
-99
Jan-
00
Feb
-00
Mar
-00
Apr
-00
May
-00
Jun-
00
Jul-
00
Aug
-00
Sep-
00
6% reduction inLDL 10% reduction in adverse cardiac events
VISN 20
Mean LDL values by VAMC
95
100
105
110
115
120
Dec
-98
Feb
-99
Apr
-99
Jun-
99
Aug
-99
Oct
-99
Dec
-99
Feb
-00
Apr
-00
Jun-
00
Aug
-00
Oct
-00
Dec
-00
Feb
-01
Apr
-01
Jun-
01
463 531 648 653 663 668 687 692
0102030405060708090
100
Dec-98
Feb-9
9
Apr-99
Jun-9
9
Aug-99
Oct-9
9
Dec-99
Feb-0
0
Apr-00
Jun-0
0
Aug-00
Oct-0
0
Dec-00
Feb-0
1
Apr-01
Jun-0
1
LDL Measurement LLA Treatment Patients at Goal (LDL<100)
QA manager distributed a copy of the LMMS report to providers
The Paper POC reminder intervention starts
Intervention ends
Barriers and Facilitators: Site G
• Appointment times too short to accomplish preventive care
• No opinion leader• No follow-up to promote
physician response• Lack of intervention
team time to promote intervention
• VA providers are more conscientious about meeting guidelines than private sector providers
• Multidisciplinary team• Buy-in was good
because of evidence basis of intervention
Site H Electronic Clinical Reminder Intervention
• When interventionists returned from Seattle kickoff meeting they presented the electronic clinical reminder to providers during a staff meeting and an e-mail
• In August 1999 the IHD-PCE reminder was turned on for providers
• One of the interventionists received patient data in early Jan 2000.