multiple methods of implementing evidence based best
TRANSCRIPT
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
disease
• Smaller Scale Context– Pre-intervention assessment, Round 1a– Follow up, Round 1c
• Facilitation– Interventions, Round 1b
VHA Is a Large, Integrated System
• Over 1300 facilities spread across the United States– 163 Medical Centers– 850 Ambulatory Care and
Community Based Outpatient Clinics
– 206 Counseling Centers– 137 Nursing Homes– 43 Domiciliaries
• Over 200,000 employees in the VHA
• Over $26 billion in health care spending
• 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
The QUERI Mission
Eight QUERI GroupsFocused on Specific Health
Conditions
• Chronic Heart Failure (CHF)
• Diabetes (DM)• HIV/AIDS (HIV)• Ischemic Heart Disease
(IHD)
• Mental Health (MH)– Includes both Schizophrenia
and Depression
• 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)
0102030405060708090
100
Dec-9
8
Feb-9
9
Apr-99
Jun-9
9
Aug-99
Oct-9
9
Dec-9
9
Feb-0
0
Apr-00
Jun-0
0
Aug-00
Oct-0
0
Dec-0
0
Feb-0
1
Apr-01
Jun-0
1
LDL Measurement LLA Treatment Patients @Goal (LDL < 100)
0102030405060708090
100
Dec-9
8
Feb-9
9
Apr-99
Jun-9
9
Aug-99
Oct-9
9
Dec-9
9
Feb-0
0
Apr-00
Jun-0
0
Aug-00
Oct-0
0
Dec-0
0
Feb-0
1
Apr-01
Jun-0
1
LDL Measurement LLA Treatment Patients @ Goal (LDL <100)
0102030405060708090
100
LDL Measurement LLA Treatment Patients @ goal (LDL < 100)
0
20
40
60
80
100
Dec-9
8
Feb-9
9
Apr-99
Jun-9
9
Aug-99
Oct-9
9
Dec-9
9
Feb-0
0
Apr-00
Jun-0
0
Aug-00
Oct-0
0
Dec-0
0
Feb-0
1
Apr-01
Jun-0
1
LDL Measurement LLA Treatment Patients @Goal (LDL < 100)
0
20
40
60
80
100
Dec-9
8
Feb-9
9
Apr-99
Jun-9
9
Aug-99
Oct-9
9
Dec-9
9
Feb-0
0
Apr-00
Jun-0
0
Aug-00
Oct-0
0
Dec-0
0
Feb-0
1
Apr-01
Jun-0
1
LDL Measurement LLA Treatment Patients @Goal (LDL < 100)
0
20
40
60
80
100
LDL Measurement LLA Treatment Patients @ Goal (LDL<100)
0102030405060708090
100
Dec
-98
Feb-
99A
pr-9
9Ju
n-99
Aug
-99
Oct
-99
Dec
-99
Feb-
00A
pr-0
0Ju
n-00
Aug
-00
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-00
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-00
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01A
pr-0
1Ju
n-01
LDL Measurement LLA Treatment Patients @ Goal (LDL<100)
Context: Round 1c
• Very difficult to measure “success”– Clear that some interventions had fallen apart
without accomplishing much– Clear that some interventions were continuing– Unclear what dose there had been of any
intervention– Massive secular trend
• Conducted qualitative follow up study– ~6 months after intervention phase ended– Interviewed “key players” involved in intervention in
each facility (54)
Summary of Facilitators Overall
• Evidence– Wide acceptance of evidence-based finding– High level of enthusiasm for delivering care based
on evidence
• Context– General support from front line clinicians and
managers
• Facilitation– High level of interest from active, respected
clinicians
Summary of Barriers Overall
• Evidence– Some disagreement about goal statements based
on available evidence
• Context– Perceived lack of resources
• Time, energy, space
– Relatively low priority for quality improvement• “We’re doing well on the EPRP reports”
• Facilitation– Insufficient planning for active, engaged facilitation
www.va.gov/resdev
www.hsrd.research.va.gov/research/queri
• Publications: – Newsletters (QUERI Quarterly,
other HSR&D)– QUERI Fact Sheets
• Project, publication databases• Links to QUERI center websites• Grant solicitations, new initiatives
Site A Lipid Clinic Intervention
• Lipid Clinic opened October 15, 1999
• Pharmacist-run clinic based on provider referral
• Hours were 10-11am and 12-3pm Fridays
Process Variables and Outcomes for Site A
0102030405060708090
100
LDL Measurement LLA Treatment Patients at Goal (LDL<100)
Kickoff Meetingin Seattle
Cardiologist presents LMMS Study during Primary care staff meeting
Lipid Clinic officially opens
Site B Combined Audit/Feedback Intervention
• Audit/Feedback: Providers were e-mailed a list of IHD patients ranked by LDL-c level excluding patients without LDL measurement
• 98 providers in all firms were sent e-mails• Pharmacist Case Management: Pharm D
Resident identified high-risk patients and intervened with providers and their patients in one clinic.
• PharmD only intervened with 5 patients during the time of the intervention.
Process Variables and Outcomes for Site B
0102030405060708090
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LDL Measurement LLA Treatment Patients @Goal (LDL < 100)
Audit/Feedback intervention starts May 2000 and continues until Jan 2001
Pharmacist case management intervention starts
Pharmacist case management intervention ends
Barriers and Facilitators: Site B
• Prevention is given a low priority in this facility (lack of time)
• Lack of communication between services
• No central leadership
• Good fit between skills and experience and implementers
• Buy-in was considered “very good”
• Management was considered supportive
Site C Combined Audit/Feedback Intervention
• Audit/Feedback– Providers were e-mailed a list of IHD
patients ranked by LDL-c level;
• Patient Education– IHD patients were sent a letter stating the
importance of maintaining a LDL-c cholesterol below 100 mg/dL, a brochure, and two pages of resources
Process and Outcome Variables for Site C
0102030405060708090
100
LDL Measurement LLA Treatment Patients @ Goal (LDL <100)
Kickoff Meeting on site
Providers were sentan e-mail informing them of the interventions
632 letters were sent to patients
Providers were sent a list of IHD patients with rank order of LDL
Barriers and Facilitators: Site C
– 20 minute appointment not enough time to address prevention
– Reluctance by some providers to turn over care to allied health providers
– Roles were poorly defined– Staff time to address
patient lists– Quality of data in first
patient list compromised buy-in from provider staff
• Chief of Ambulatory care provided strong leadership
• Kickoff meeting and working meeting were good team building opportunities
• Compilation of data and expertise of IRM staff
Site D Multiple Interventions
• Ten proposed interventions, two successful• Cardiology Clinic I: Paper POC Reminder:
Initiated by Cardiology Coordinator. Continues today
• Home Site: Computerized Order template adds fasting lipid panels to cardiac cath and cardiology admissions. Continues today
Process Variables and Outcomes for Site D
0102030405060708090
100
LDL Measurement LLA Treatment Patients @ goal (LDL < 100)
Kickoff Meeting
In-service at primary care staff meeting at satellite clinic
Paper POC reminder in cardiology clinic at Satellite Cardiology Clinic
Fasting lipid panel added to order template in CPRS (cardiology admissions and cath patients)
CCU informational In-service for nursing staff in Home Site
Barriers and Facilitators: Site D
• Too many interventions proposed
• Team: no planning/no protocol, no communication, poorly defined roles
• Limited resources: lack of time of intervention staff
• Lacked buy-in from nursing staff and management
• Easy to integrate satellite cardiology clinic intervention into already existing job functions
• Good working relationships in satellite cardiology clinic
Site E Lipid Clinic Intervention
• Approved in April 1999 by the PT&N Committee
• Pharmacist-run clinic based on provider referral
• Initially daily clinics M-F 1:30 - 3:30 pm
• PharmacoManagement Clinic started in Jan 2000.
Process Variables and Outcomes for Site E
0
20
40
60
80
100
LDL Measurement LLA Treatment Patients @Goal (LDL < 100)
Lipid Clinic Starts
Kickoff MeetingIn Seattle
CME Meeting: with national expertand LMMS Research Staff
*Clinical pharmacist leaves VA*
PharmD starts PharmacoManagement Clinic
PharmD receives permission to call patients on Seattle Data list
Barriers and Facilitators: Site E
• Lack of buy-in from providers
• Lack of resources: space, time, personnel
• Patients live far away• Team had problem with
data from LMMS team
• Having intervention come from outside source (administrative buy-in)
• Fellow colleagues who referred patients to clinic
Site F Multiple Interventions
• ER orders for IHD patients were changed to add lipid profile & LFTs; Start Simvastatin, review ASA, ACE inhibitor, B-blocker use; repeat LFTs & lipids in 6 weeks
• Admission orders for ICU/ACU changed to include LFTs and statins w/6 week f/u
• Target education program for nursing staff• Pharmacist-run Lipid Clinic
Process and Outcome Variables for Site F
0102030405060708090
100
LDL Measurement LLA Treatment Patients @ Goal (LDL < 100)
Addition to computerized order templates to include fasting lipid profile and Simvastatin
Kickoff meeting in Seattle
Nursing/Pharmacy/MD Staff IHD Education
Pharmacist-run Lipid Clinic opens in October 2000
Barriers and Facilitators: Site F
• Ordering labs and meds can be difficult
• There are overwhelming demands on providers
• Need for a centralized leader w/expertise of guidelines
• Team communication suffered during implementation
• Strong time and resource limitations
• Team process good during planning
• Management support from Chief of Medicine
Site G Paper POC Reminder Intervention
• Paper POC Reminder
• A sheet was placed in front of the patient’s chart at the time of the appointment.
• The sheet contained lab information, pharmacy information and text lines for a provider response to the reminder.
Process and Outcome Variables for Site G
0
20
40
60
80
100
LDL Measurement LLA Treatment Patients @ Goal (LDL<100)
Kickoff Meeting in Seattle
Intervention is presented to Medical Staff
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.
Process and outcome variables in Site H
0102030405060708090
100
LDL Measurement LLA Treatment Patients @ Goal (LDL<100)
Kickoff Meeting in Seattle
Intervention team presents study and intervention to provider staff @ Staff Meeting
IHD-PCE Reminders are turned on
Patient list is sent by Seattle team
Context: Round 2
• New VISN– VISN 19, Rocky Mountain Network– Single intervention
• Electronic IHD Lipid Reminders
– Eastern half of VISN received intervention– Western half did not
• Effort to control for secular trend
VHA Is Divided Into 21 VISNs
IHD Lipid Clinical Reminders
• Development of two national IHD reminders– Notifies clinicians if lipid panel due or ’ed
LDL– Provides relevant lab & pharmacy data– Links directly to lab & lipid lowering med
orders and progress notes
Current Status
• Evaluation of reminder still in progress• Preliminary results of provider survey
available– Suggest that non-intervention sites did not
receive intervention– With one exception intervention sites did
receive intervention– Providers in intervention sites are using the
reminders