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Using Multiple Data Sources to Understand Variable Interventions

Using Multiple Data Sources to Understand Variable Interventions. Bruce E. Landon, M.D., M.B.A. Harvard Medical School AcademyHealth Annual Research Meeting June 10, 2008. The Problem.

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Using Multiple Data Sources to Understand Variable Interventions

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  1. Using Multiple Data Sources to Understand Variable Interventions Bruce E. Landon, M.D., M.B.A. Harvard Medical School AcademyHealth Annual Research Meeting June 10, 2008

  2. The Problem • Quality improvement interventions often teach a method for improvement, rather than a specific intervention • Variability in implementation across sites • Site specific needs • Resources, leadership, etc. • Specific interventions • Variable evidence of success at the level of individual sites • What can be learned from this variability?

  3. Outline • The HRSA Health Disparities Collaboratives • What do organizations do in a QIC? • The EQHIV Study in Ryan White Funded HIV Clinics • What accounts for negative results? • How reliable are organizational assessments? • Conclusions

  4. IHI and the Breakthrough Series • Collaborative method for improving the quality and value of health care • Short term (6-18 months) programs that bring together learning teams from multiple organizations • Developed by IHI in 1995 • Over 50 collaboratives (just by IHI) • Over 2000 improvement teams

  5. The IHI Learning Model Setting Aims Measuring Progress Selecting/Implementing Changes Testing Changes Source: The Institute for Healthcare Improvement

  6. Health Disparities Collaboratives

  7. Looking Inside the Collaboratives • Interventions systematically recorded by each site in “monthly reports” • Coding instrument developed to categorize interventions based on the CCM and stage of implementation • Coded by two trained abstractors independently

  8. The Chronic Care Model Source: Wagner et. Al, The McColl Institute

  9. Sub-Categories Care management roles Practice team Care delivery Proactive follow-up Planned visit Visit system changes Examples Nurses take on more patient follow-up tasks Multidisciplinary team meetings Standardize specialist referral process Call patients who are overdue for visit Targeted reminders in charts prior to visits Group visits Delivery System Design (Changes in the organization of human resources)

  10. Sub-categories Institutionalization of guidelines, protocols and prompts Provider education Expert consultation support Examples Structured forms to replace progress notes Podiatrist teaches nurses to do foot exams Case conferences with specialists Decision Support (guidance for provider behavior or decision-making)

  11. Quality Improvement Activitiesby CCM Categories

  12. Intensity of Quality Improvement Activities, by CCM Categories

  13. Relationship between QI Activities and Quality Change • No significant relationships between: • Total number of activities • Mean impact score of activities • % implemented • % institutionalized • Number graded as “high” or “very high” And changes in observed quality of care

  14. Limitations to This Type of Analysis • Dramatic loss of power when changing from a controlled design to an observational design with n=~40 • One size might not fit all • Specific interventions are designed to meet local needs and might not be transferrable • How to account for local context?

  15. The EQHIV Study Landon, B. E. et. al. Ann Intern Med 2004;140:887-896

  16. Possible Explanations • The intervention did not work • Clinics were not “prepared” for the intervention (or ready) • Change might be required across the spectrum of the CCM to achieve results • Structure and culture at individual clinics might impede change • Improving chronic care requires broad across the board changes

  17. Assessment of Organizational Change • Pre/post surveys of: • Clinic directors • Clinicians • Results show modest pre/post changes in 3 domains of the CCM, with little change in the other domains • System changes were likely not sufficient to lead to broad improvements

  18. How to Increase Reliability of Organizational Surveys? ρr Source: Marsden, Landon, et. al. HSR, 2006.

  19. Other Potential Methods • Pre/post surveys of clinicians/support staff/leadership • Site visits/qualitative data • Pre surveys to assess “readiness for change” • ….and so on

  20. Conclusions • Additional data sources are needed to understand what happens at the individual clinic level • These data can be useful for understanding more about the implementation of the interventions • Data are limited by small sample sizes, lack of a control group, and low reliability • Many questions remain unanswered (e.g., What other components of care are important (leadership, resources, composition, etc.)?)

  21. Final Thoughts • Quality Improvement is difficult • Studying Quality Improvement is particularly challenging • Quality Improvement Implementation Research is a rich area that brings together many disciplines

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