Using QUERI & Implementation Science Theories and Frameworks to Improve Access and Equity

1. Using QUERI & Implementation Science Theories and Frameworks to Improve Access and Equity S. Randal Henry, DPH, MPH QUERI HIV/Hepatitis C

2. Preface

3. Does implementation of disparities reduction programs differ from general quality improvement interventions? How can implementation science contribute to disparities reduction research? How can collaboration and partnership-building contribute to the reduction of health disparities? How can we develop and implement programs that address the need for comprehensive, integrated care for patients with multiple co-morbid conditions that require care across multiple services lines? Overview

4. The VA Healthcare System: An Ideal Environment for Disparities Research • Patients are racially and ethnically diverse and many are economically disadvantaged • Access to healthcare is similar across veteran populations, eliminating this key reason for disparities in health care • Computerized clinical and administrative national databases on veterans served

5. VA HSR&D and Disparities Research • The VA supports disparities research • Improving access to care and reducing health disparities is a priority research focus • Established the Center for Health Equity Research and Promotion (CHERP) and Center for Disease Prevention and Health Interventions for Diverse Populations

6. Poll Question • Does the implementation of access and equity improvement interventions differ from general quality improvement (QI) interventions? • Yes • No

7. Cyber Seminar Goals

8. CyberSeminar Goals • Encourage the quality improvement community to address impaired access and inequitable distribution of care • Encourage the access and equity community to utilize implementation research • Promote the use of implementation science to reduce health disparities 

9. Introduction: The VA is committed to delivering high quality healthcare care in an equitable manner.

10. What are Health Disparities?

11. Health disparities are differences… • in the quantity and quality of healthcare provision • in the prevalence, mortality, and burden of disease and other adverse health conditions • not due to access related factors, clinical need, preferences, or appropriateness of the intervention (IOM)

12. Poll Question In the course of your research or clinical practice, have you identified a health disparity? Yes? No?

13. Evidence of disparities • Evidence of racial and ethnic disparities in health care is consistent across a range of illnesses and healthcare services. (Smedley et al) • Disparities have been demonstrated in the Veterans Affairs (VA) healthcare system. Smedley B, Stith A, & Nelson AR.Unequal treatment confronting racial and ethnic disparities in healthcare. City: National Academies Press (US), 2003.

14. Associated with age, gender, race/ethnicity and income: More consistently observed for processes that: entail more risk and require more intensive decision making & communication require more effort on the part of patients and/or providers medication adherence Associated with geographic location: When compared to their urban counterparts, rural veterans have; worse health-related quality-of-life report less access to care use fewer healthcare services are more dependent on the VA for their healthcare services travel burden to specialty services is substantially greater research on rural veterans health and health care is lacking. Inequities within the VA Saha S, Freeman M, Toure J, et al. Racial and ethnic disparities in the VA healthcare system: a systematic review. 2007 Jun. Department of Veterans Affairs HSR&D

15. Vulnerable Patient Groups • Racial/ethnic minorities • Women • Homeless • Elderly • Low socioeconomic status • Stigmatizing medical or psychiatric illness • Diminished autonomy

16. Disparities by QUERI

17. Disparities By Clinical Content Area

18. Disparities By Utilization/Outcome Measure Saha S, Freeman M, Toure J, Tippens K, Weeks C. HSR&D Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review (2007)

19. Polling Questions #2 • What is the key barrier to improving access and equity for veterans? • Individual/patient-level factors • Organizational/institutional factors

20. Which VA Programs Address Access and Equity?

21. The VA may be able to address individual and institutional barriers to care • A greater understanding of the prevalence and influence of these processes is needed and should be sought through research

22. Center for Health Equity Research and Promotion (CHERP) • HSR&D Center of Excellence • Promote equity and quality in health and health care • A collaboration among key entities within VISN4  • Investigators played key roles in the development of Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review

23. VA Center for Minority Veterans • Goals • Provide and promote the use of VA programs, benefits, and services use by minority veterans • Make benefits and services more accessible to minority veterans • Evaluate current programs and make recommendations on how VA can better serve minority veterans

24. Office of Quality and Performance (OQP) • Operational focus on disparities • Race/ethnicity • Gender • OQP custodian of rich source of data for health disparities research • OQP Chronic pain (race) • Alcohol Counseling (race) • Immunization (gender) • Quality of Care (mental health, MS, SCI, Chronic illness, rural/urban)

25. Poll Question • What do you think is the major barrier to addressing disparities? • Documenting/diagnosing/identifying organizational factors that contribute to disparities • Designing/delivering disparities reduction programs • Creating policy changes • Overcoming organizational barriers

26. What is Implementation Science? How can it help reduce identified health disparities?

27. Implementation Science (IS) • Implementation Science is the study of the systematic uptake of knowledge and the implementation of that knowledge into routine organizational practice (and everything that facilitates or impedes it) • Typically conducted in health services settings • Includes examination of the influence of contextual factors (e.g. organizational policy) and individual factors (e.g. healthcare professionals) on organizational behavior

28. Implementation Science can… • Develop standards for evaluating access and equity • Generate new insights and generalizable knowledge regarding dissemination / implementation of disparities reduction • Develop, test and refine disparities reduction theories, hypotheses, models and principles • Determine the relative effect of quality improvement interventions among patients at highest risk for impaired access and inequitable care

29. Four Implementation Science Frameworks that can be used to Assess Access and Equity

30. CHERP Conceptual Model for Health Disparities Research Detect disparities in health or health care First Generation Understand reasons for disparities Second Generation Develop interventions to eliminate disparities Third Generation Kilbourne et al. American Journal of Public Health, December 2006

31. Behavioral Model of Vulnerability Chart Adapted from: Gelberg, L, Andersen RM, and Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people (2000)

32. Successful Implementation = f (E, C, F) Evidence = Research; Clinical experience; Patient experience; & Local knowledge Context = Receptive context; Culture; Leadership; & Evaluation Facilitation =Purpose; Role; Skill & Attributes PARIHS Framework

33. PRECEDE PROCEED Framework PRECEDE Phase 5 Administration and Policy Diagnosis Phase 4 Educational and Organizational Diagnosis Phase 3 Behavioral and Environmental Diagnosis Phase 2 Epidemiological Diagnosis Phase 1 Social Diagnosis Health Promotion Predisposing factors Health education Reinforcing factors Behavior and Lifestyle Quality of Life Health Policy regulation organization Enabling factors Environment Phase 6 Implementation Phase 7 Process Evaluation Phase 8 Impact Evaluation Phase 9 Outcome Evaluation PROCEED

34. Polling Questions # 3 • What is the key barrier to Quality Improvement (QI) in medical care delivery? • Individual factors • Societal Factors • VA related organizational/institutional factors

35. IV. Utilizing the QUERI Model to Improve Access and Equity

36. QUERI Mission • Enhance the quality and outcomes of VA health care by systematically implementing clinical research findings and evidence-based recommendations into routine clinical practice. • practice needs determine the research agenda • research results determine interventions that improve the quality of patient care.

37. QUERI Four-Phase Implementation Research Framework PhaseStudy TypeForm of Evaluation Pre-trial Program Conceptual design of implementation program and underlying design (logic) model from theory, prior empirical research Phase 1 Pilot / Pilot test, assess feasibility, formative evaluation and refinement, Formative develop intervention/evaluation protocols Phase 2 Efficacy Small-scale rigorous trial in controlled settings with ongoing intervention support; emphasis on internal validity Phase 3 Effectiveness Large-scale rigorous trial under routine conditions in varied settings; emphasis on external validity Phase 4 Monitoring Ongoing monitoring and feedback

38. 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 outcome and system improvements Document improvements in health-related quality of life The Classic Six-Step QUERI Process

39. V. Next Steps UsingImplementation Science to Study and Promote Equity

40. Future Directions for VA Disparities Research • Leading investigations to better understand the patient, provider, and system level causes of health disparities • Developing and evaluating new interventions to reduce health disparities • Improve the quality and equity of VA health care through effective collaborations and dissemination of research findings • Ensuring that health care equity is considered an integral component of health care quality in VA

41. Poll • What is the best method to improve the overall health status of all veterans? • Develop specific programs for the most vulnerable (high-risk) patient groups • Develop universal interventions (designed to improve the health of all)

42. Summary • The VA is an ideal setting to conduct first, second, and third generation disparities research • The VA HSR&D is committed to supporting this line of investigation and to training the next generation of disparities researchers • The VA is a national leader in advancing the field of disparities research, generating findings highly relevant to other health care systems

43. VA HSR&D CHERP VA CIPRS VA QUERI (esp. HIV/Hepatitis C) OQP Acknowledgements 43