IHD-QUERI Update 2011 Research and Methodology Committee Review Meeting -- January 26, 2011

1. IHD-QUERI Update 2011Research and Methodology Committee Review Meeting -- January 26, 2011 • Brief overview – IHD in VA • IHD QUERI Update • Productivity • Innovative projects • Extensive network of partners • Implementation Framework ≈ Strategic Plan (CART-CL=prototype) • Focus on systems of care Stephan D. Fihn, MD, MPH John Rumsfeld, MD, PhD Christian Helfrich, PhD Michael Ho, MD, PhD Blake Wood, MS

2. Ischemic Heart Disease Acute IHD Care Chronic IHD Care

3. State of IHD Care in the VA

4. VA IHD Care Compared to non-VA AHA Annual Statistical Update 2011

5. IHD-QUERI Accomplishments:Past 3 years • 22 IHD QuERI-affiliated investigators • Funding • 20 studies led by IHDQ-affiliated investigators during past 3 years with $7.5 million in funding, including 8 QuERI RRPs • Plus: • CART development ($5.3 m) • QIR ($240k) • Patient-aligned Care Team national evaluation center ($990k) • 77 publications (2008-2010)

6. Highlights of Recent IHD-QUERI Accomplishments Examples • Cardiac Care Follow-up Clinical Study (CCFCS) • Cardiovascular Assessment Reporting and Tracking System (CART)

8. Actions Taken • New Chief Cardiology Consultant (Dr. Jesse) • National steering committee (including PCS, operations, research, OQP) • VISN action plans • New performance measures • National training • Technical assistance projects • Major investment in new equipment • Updated clinical guidelines (with AHA/ACC) • National cath lab software package (CART-CL)

9. CCFCS: AMI mortality within VHA is comparable to Medicare-funded hospitals Fihn SD, et al. BMC Cardiovascular Disease 2009

10. CCFCS: Potential for interaction between antiplatelet medication and PPIs Ho PM, et al. JAMA 2009

11. Cardiovascular Assessment Reporting and Tracking System for Cath Labs (CART) Missions of CART • Clinical care • Quality improvement • Research

12. Current Status of CART(2004-2011; N=77)

13. CART: Innovative Program for Post-Market Device Surveillance 2007: 1 UED Reported from VA to FDA ???

14. CART-FDA Device Surveillance August 15, 2006-September 31, 2009 26,554 PCI REPORTS Entered in CART 308 DEVICE-RELATEDEvents Reported in CART from 47 sites 215 LEVEL I Not Specific to the Medical Device (deidentified – no PHI) 78 LEVEL II Potentially Device-Related ( details for novel events – no PHI) 15 LEVEL III Potentially Device-Related Patient Complications (FDA reportable MedWatch 3500A)

15. CART Active Sites and Adoption

16. Median Rates for Implementation Phases 1 ± 1.8months 3 ± 4.2months 1 ± 2.5months 1 ± 7.6months

17. CART IMPLEMENTATION: Key Barriers Contentment with Current Processes Staff Resource Concerns Lack of Interfacing with External Systems

18. CART IMPLEMENTATION: Key Facilitators Integration with the VA EHR Future Research Potential Desire to Improve Quality

19. QuERI Steps Evidence based Practice Implement Improvement programs Evaluate Improvement Programs Measure Gaps Develop Measures and Data Resources Develop Clinical Evidence

20. Implementation Practice Operational partnerships Evidence based Practice Implement Improvement programs Evaluate Improvement Programs Measure Gaps Develop Measures and Data Resources Develop Clinical Evidence Data systems Evolving systems of care

21. Implementation Practice Operational partnerships Evidence based Practice Implement Improvement programs Evaluate Improvement Programs Measure Gaps Studying interventions built into systems of care Develop Measures and Data Resources Develop Clinical Evidence Data systems Evolving systems of care Understanding the influence of organizational context

22. Robust IHD-QUERI Partnerships

23. Ischemic Heart Disease Acute IHD Care IHD Care Chronic IHD Care Leveraging CCFCS and CART to identify gaps in care RF management Gaps in quality metrics Failure to optimize systems of care Gaps in longitudinal care Patient adherence Suboptimal coordination/transitions

24. IHD as a Continuum Risk factors: (e.g. hypertension and hyperlipidemia) Coronary artery disease: i.e., acute coronary syndromes and Treatment including PCI Sequelae of CAD: i.e., CHF and chronic therapies And device therapy (ICD)

25. IHD as a Clinical Continuum

26. Strategic focus Strategic foci • Leveraging systems of care • Emphasis on effectiveness and safety • Team-based, patient-centered, coordinated care • Longitudinal care IHD QUERI Goals Proposed projects Focus on systems of care and strategic partnerships as opposed to specific clinical conditions. Integrations with VHA strategic objectives.

27. Goal 1: Leverage information systems to improve quality and safety of care • Improve availability of timely clinical information at point of decision making • Track changes in quality of care and outcomes for AMI • Develop implementation tools and interventions at program level • Identify organization factors association with utilization of clinical data

28. Objective 1-1: Improve availability of timely clinical information at point of decision making • Example: Appropriateness of PCI • Validate data elements in CART needed to make appropriateness classification • Assess variation in appropriateness of PCI APCI-RRP and Bradley CDA

29. Objective 1-2: Track changes in quality of care and outcomes for AMI • Longitudinal effectiveness and safety • Bleeding from triple anti-thrombotic therapy • Prevalence, care, and outcomes of newly diagnosed diabetes • Clopidogrel use in CKD patients IHAMI and CCFCS

30. Objective 1-3:Develop implementation tools and interventions • Example: Reducing radiation dose for invasive cardiac procedures • Develop toolkit to reduce radiation used for invasive cardiac procedures • Pilot test toolkit at 2 VA cath labs Radiation-RRP

31. Objective 1-4: Identify organizational factors association with utilization of clinical data • Example: ORCA • Prospectively validate measure of organizational readiness to change against operationally-relevant outcomes • Emphasis factors that are actionable • Collaboration among 4 QUERIs ORCA

32. Goal 2: Improve cardiovascular risk factor management by integrating new programs into evolving systems of care • Identify and understand differences in risk factor management and their causes • Identify organizational and contextual factors that influence risk factor management • Develop implementation tools and interventions at program level to improve care and efficiency

33. Objective 2-1: Understand differences in risk factor management and causes • Determine BP and LDL control in year following catheterization among CAD patients • Determine specific patient, provider, and system factors associated with BP and LDL control Maddox CDA

34. Objective 2-2: Identify organizational and contextual factors that influence risk factor management • Example: Organizational correlates of medication adherence • Assess roles of organization, provider and patient-level factors in medication adherence • Specifically examines structural factors thought to improve adherence (e.g., pharmacy FTE) OCAM

35. Objective 2-3: Develop implementation tools and interventions at program level to improve care and efficiency • Develop intervention toolkit • Incorporates formative evaluation focusing on contextual factors • Collaboration with Stroke QuERI • Develop and test centralized call center to support SMILE-BP intervention • Addresses needs of smaller facilities with limited resources SMI IIR SMILE-BP RRP VALUE SDP • Demonstrated telephone-based staged matched intervention improved BP control

36. IHD-QUERI Goals: Next 3-5 Years

37. Leveraging established platforms for current projects ORCA Radiation RRP OCAM Maddox CDA SMILE BP APCI-RRP Clopidogrel RRP CART and CCFCS and IHD-QUERI partnerships and collaborations

38. Example of Innovative Work Leveraging Established Platforms Link information systems (i.e., CART-CL and pharmacy) to provide real-time decision support and safety alerts Clopidogrel-RRP

39. Real-time Assessment of Whether Clopidogrel is Filled at Hospital Discharge

40. Leveraging Collaborations with Partners IHD QuERI Research Coordinating Center Seattle, WA IHD QuERI Clinical Coordinating Center and VA REAP Denver, CO Jeffrey Whittle Affiliate Investigator Milwaukee, WI Diabetes QuERI Ann Arbor, MI PACT Evaluation Center and QIR Seattle, WA Michael Fischer Investigator Chicago, IL Anne Sales VA IPEC Michigan Paul Heidenreich CHF QuERI Palo Alto, CA Sundar Natarajan Affiliate Investigator New York, NY VA PCS, ACC/NCDR, FDA National Device Surveillance Center Washington, DC Cynthia Jackevicius Affiliate Investigator Los Angeles, CA Stroke QuERI Indianapolis, IN Michael Ho, Thomas Maddox, Tom Tsai Affiliate Investigators Denver, CO Salim Virani Affiliate Investigator Houston, TX Mental Health QuERI Little Rock, AR

41. Future Projects Leveraging Collaborations with Partners

42. Project to Study Implementation of CART-Eletrophysiology: Leverage Operational Partnerships CART/PCS CART-EP SDP National Cardiac Device Surveillance Program NCDR-ICD registry

43. Project to Improve Transitions of Care: Leverage Operational and QUERI Partnerships QIR -Predictve modeling & care management PACT Transitions-RRP IHD QUERI CHF QUERI

44. New Members of IHD-QUERI • Co-Clinical Coordinator • Mike Ho • Administrative Coordinator and Co-Implementation Research Coordinator • Blake Wood • New investigators/EC committee members • Tom Tsai (interventional cardiologist) Paul Varosy (electrophysiologist), Steve Bradley (general cardiologist), Sundar Natarajan (internist) Paul Hebert (health economist), Anne Sales (nurse) and Cynthia Jackevicius (pharmacist)

45. Summary • Accomplishments to date • Productivity • Innovative projects • Extensive network of partners • Implementation Strategy ≈ Strategic Plan • Focus on systems of care

46. Appendices and additional slides