Implementing the Findings of Comparative Effectiveness Research

David Atkins MD, MPH Director, QUERI Program

What Ill Say

Many of the challenges of translation of research into practice are similar inside VA and outside
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Difficulty of changing provider behavior, moving complex organizations

What we have learned is very relevant to other systems Certain unique aspects of VA organization HAVE made it easier for us to achieve change
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HIT, integration of care, alignment of incentives

Many of these features CAN and ARE being adopted by outside organizations to improve success

Closing the Quality Gap

Uneven delivery of effective care welldocumented Only 50% of effective interventions are reliably delivered If we only focus on GENERATING more information on comparative effectiveness, without attending to how to IMPLEMENT it, we will not improve quality or value or provide return on CER investment.

The 3 Translational Blocks

Dougherty, D. et al. JAMA 2008;299:2319-2321.

Copyright restrictions may apply.

CER and Implementation

How can implementation research help us get the most reward from investment in CER?
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Is implementing CER different than implementing any new evidence?

How can we apply CER to identify the most effective implementation strategies?

Building a Coordinated Implementation Strategy in VA - QUERI

Established in VA in 1998 as part of sweeping reforms in VHA Designed to speed the uptake and spread of evidence-based care throughout the VA Based on principles of implementation science Understanding and overcoming barriers to adoption of new practices

QUERI Coordinating Centers

Polytrauma/Blast Injury Minneapolis, MN Ischemic Heart Disease Seattle, WA

Spinal Cord Injury Hines, IL

Diabetes Ann Arbor, MI

CHF-QUERI Palo Alto, CA

STROKE-QUERI Indianapolis, IN

HIV/HEPATITIS C-QUERI Greater Los Angeles Substance Abuse Houston, TX

Mental Health Little Rock, AR

QUERI Centers

QUERIs Research/Implementation Pipeline

Identify Research Area Identify Best Practice Implement Intervention & Document outcome

Clinical Research / Guideline Development Mainstream Health Services Research

Implementation Research

Implementation Policy, Improved Health

Assess Existing Practice Phase 1 Pilot Projects Phase 2 Small-Scale Demonstration s Phase 3 Regional Demonstrations Phase 4 National Rollout

Why Dont Clinicians and Patients Select the Best Treatments

Knowledge gaps dont know latest evidence Skills gaps not trained to deliver new interventions System barriers organization, leadership, support, time, resources Technology barriers lack right information

Evidence Synthesis Program

4 centers (including a coordinating Center) Take advantage of capacity of AHRQ Evidenced-based Practice Centers Quick turn-around reviews of Veteranspecific topics (e.g. suicide prevention, disparities in VA) Apply Veteran-specific lens to research synthesis Inform VA policies

Tools Used By VA to Facilitate Implementation

Provider Education
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CME, Clinical Practice Guidelines MyHealtheVet, self-management support, care managers Electronic Reminders Computerized Decision Support

Patient Education:
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HIT: Electronic Health Record

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National Formulary Policies Performance Measures and Reporting Incentives

Example: Implementing Collaborative Care to Improve Depression Rx

Multiple studies demonstrate advantage of collaborative care for depression Mental Health QUERI Program -- TIDES
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Demonstrate success at a few facilities Show it can be rolled out broadly Test its transferability to different settings (e.g. substance abuse clinics)

What is Needed for Spread and Adoption

Tools:
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Care manager training manual Redesign tools for local champions, Fidelity tools In-person training (continuing education services) Train the Trainer

Training
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IT
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Care management assessment and follow-up Consultation software TIDES scripts Case load management software Fo Formalized training curriculum

Implementation of System Change Collaborative Care of Depression

Depression Collaborative Care Model

VISN 10

Akron Canton Youngstown Beaumont Pensacola Lufkin

Outpatient utilization Patient satisfaction Hospitalization rates Barriers to collaboration Collaborative care costs Implementation fidelity Sustainability in 1st-generation sites

1st-generation sites

Single site

3 VISNs 9 sites

18-30 sites 4 VISNs

2nd-generation sites

Black Hills Twin Ports Sioux Falls

Depression symptoms Depression severity Anti-depressant meds

BRIDGE to National Rollout

National Rollout

Comparative Effectiveness Research of Implementation

Many options for facilitating adoption of CER Tradeoffs of costs, effectiveness, feasibility
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E.g. Reminder fatigue

We need to compare different approaches to find most efficient combinations Example: What is relative yield of audit and feedback, national performance

What Have We Learned From Implementation Science?

Multiple models to explain change process Common factors:
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Importance and priority of change (leadership commitment) Local context and capability Nature of change Local champions, tools, training Leadership, resources, IT, inertia

Most changes require active facilitation

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Barriers differ with specific context

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IOM Priorities for CER

Many of the top priorities involved Health Care Delivery System interventions (23 of 100) Compare the effectiveness of dissemination and translation techniques to facilitate use of CER Compare the effectiveness of comprehensive care coordination programs in chronic disease.

Lessons from VA and QUERI

No single or simple solution for implementation
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Context is critical: intervention, setting, patient Education may be necessary but never sufficient

HIT tools can be an important component of implementation Effective implementation may require redesigning the care process

Bridging the Translation Gap