Knowledge Utilization International Conference Quebec, Canada September 25, 2003

1. Quality Enhancement Research Initiative Multiple Methods of Implementing Evidence Based Best Practices: Examples from QUERIHealth Services Research & Development ServiceDepartment of Veterans Affairs Knowledge Utilization International Conference Quebec, Canada September 25, 2003

2. 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

3. 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 VHA Is a Large, Integrated System

4. 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

5. VHA Is Divided Into 21 VISNs

6. The QUERI Mission To enhance the quality and outcomes of VA health care by systematically translating or implementing evidence-based research findings into routine clinical practice

7. 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) Eight QUERI GroupsFocused on Specific Health Conditions

8. Identify high risk/high burden conditions Identify best practices Define existing practice patterns in VA and variations from best practices Identify (or develop) and implement programs to promote best practices Document patient outcomes and system improvements Document improvements in health related quality of life The Six-step QUERI Process

9. QUERI’s Research/Implementation Pipeline Clinical trials, guideline development New question Data, measures Clinical research, mainstream HSR Outcomes studies Ongoing evaluation and feedback Implemen-tation policy Variations studies National Rollout Implementation research Program, tool development Pilot projects Regional demonstrations Small-scale demonstrations

10. 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

11. 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). • 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/

12. 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

13. VHA Is Divided Into 21 VISNs

15. 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

16. Mean LDL for IHD Patients on Statins 6% reduction in LDL  10% reduction in adverse cardiac events VISN 20

17. Mean LDL values by VAMC

19. 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)

20. 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

21. 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

22. www.va.gov/resdevwww.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

23. 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

24. Process Variables and Outcomes for Site A Lipid Clinic officially opens Kickoff Meeting in Seattle Cardiologist presents LMMS Study during Primary care staff meeting

25. 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.

26. Process Variables and Outcomes for Site B Pharmacist case management intervention ends Pharmacist case management intervention starts Audit/Feedback intervention starts May 2000 and continues until Jan 2001

27. 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 Barriers and Facilitators: Site B

28. 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

29. Process and Outcome Variables for Site C 632 letters were sent to patients Providers were sent a list of IHD patients with rank order of LDL Kickoff Meeting on site Providers were sent an e-mail informing them of the interventions

30. 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 Barriers and Facilitators: Site C

31. 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

32. Process Variables and Outcomes for Site D Paper POC reminder in cardiology clinic at Satellite Cardiology Clinic CCU informational In-service for nursing staff in Home Site Fasting lipid panel added to order template in CPRS (cardiology admissions and cath patients) Kickoff Meeting In-service at primary care staff meeting at satellite clinic

33. 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 Barriers and Facilitators: Site D

34. 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.

35. Process Variables and Outcomes for Site E PharmD starts PharmacoManagement Clinic  *Clinical pharmacist leaves VA* CME Meeting: with national expert and LMMS Research Staff Lipid Clinic Starts Kickoff Meeting In Seattle  PharmD receives permission to call patients on Seattle Data list

36. 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 Barriers and Facilitators: Site E

37. 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

38. Process and Outcome Variables for Site F Nursing/Pharmacy/MD Staff IHD Education Kickoff meeting in Seattle Addition to computerized order templates to include fasting lipid profile and Simvastatin Pharmacist-run Lipid Clinic opens in October 2000

39. 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 Barriers and Facilitators: Site F

40. 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.

41. Process and Outcome Variables for Site G QA manager distributed a copy of the LMMS report to providers Intervention is presented to Medical Staff Intervention ends Kickoff Meeting in Seattle The Paper POC reminder intervention starts

42. 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 Barriers and Facilitators: Site G

43. 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.

44. Process and outcome variables in Site H Patient list is sent by Seattle team IHD-PCE Reminders are turned on Kickoff Meeting in Seattle Intervention team presents study and intervention to provider staff @ Staff Meeting

45. 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

46. VHA Is Divided Into 21 VISNs

47. 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

49. 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