BACKGROUND/RATIONALE:
Some 7.1 million Americans and an estimated 250,000 Veterans actively using VHA are myocardial infarction (MI) survivors. To date, most guideline interventions focus on a single patient condition but ambulatory post-MI patients are frequently more complex with multiple co-morbidities and conflicting guidelines applicable to them. The goal of VA MI-PLUS is to develop and test an Internet-based multi-modal guideline implementation strategy for the purpose of increasing provider adherence to guidelines for complex post-MI patients.
OBJECTIVE(S):
1) Identify barriers to provider adherence to guidelines within VHA clinics; 2) Apply guideline-based performance measures to electronic medical records (CPRS) and associated administrative data; 3) Implement the interactive Internet intervention with VA-specific components, including performance feedback for CBOC clinicians; and 4) Test hypotheses on the intervention's effectiveness, sustainability, and cost-effectiveness in the VA population.
METHODS:
This is a randomized, controlled trial with the CBOC as a unit of randomization. Study investigators will recruit local project investigators (PIs) at VA facilities identified in the VAST database. The CBOC providers will be recruited using electronic and postal mail. Participating CBOCs will be randomized at the time of intervention access by a single CBOC provider. Strategies to recruit CBOC providers and maintain recruitment will be developed and employed. An electronic chart abstraction tool will be developed to obtain local CBOC performance data. An interactive Internet-based study intervention will be developed, tailored to the VHA and updated as appropriate. The existing VHA Clinical Guidelines website will be utilized as the control. Audit feedback using the achievable benchmarks of care methodology and baseline performance indicator data aggregated at the CBOC level will be provided to the study intervention providers. The change in performance of study indicators pre- and post-intervention will be compared among the control and intervention arms.
FINDINGS/RESULTS:
Data collection to date has consisted of barrier identification through case vignette surveys and focus groups of VA physicians. Identified barriers were lack of time and patient adherence issues. Also, VA physicians noted a dearth of outpatient education materials at their disposal. Additionally, the staff has discovered some issues with utilizing the VAST system to correctly identify parent facilities and their associated CBOCs, especially when reporting lines have been changed. These issues have complicated the facility recruitment process, but the study has progressed on schedule. Finally, the staff has found some difficulty in processing IRB and R&D applications, due to the multiplicity of variances in application requirements among facilities. This has been especially true for VA facilities utilizing academic institutions for the IRB review. Baseline data has been colledted from 47 participating sites.
IMPACT:
The project will produce an evidence-based and replicable state-of-the-art intervention that can be translated for "real world" use, readily disseminated, and easily adapted for other diseases. Given the VA's high priority to improve care and the high proportion of VA patients with coronary artery disease with multiple comorbidities, this study presents a unique opportunity to contribute to VA's place at the forefront of health services research while benefiting a substantial number of VA patients. In addition, the project to date has witnessed the impact of positive collaboration between VHA facilities. This multi-site project has been the first of such collaborations for many of the parent facilites and establishes a process for the implementation of future multi-site research investigations.
PUBLICATIONS:
Journal Articles
- Houston TK, Funkhouser E, Allison JJ, Levine DA, Williams OD, Kiefe CI. Multiple measures of provider participation in Internet delivered interventions. Studies in Health Technology and Informatics. 2007; 129(Pt 2): 1401-5.
- Houston TK, Funkhouser E, Allison JJ, Levine DA, Williams OD, Kiefe CI. Multiple measures of provider participation in Internet delivered interventions. Studies in Health Technology and Informatics. 2007; 129(Pt 2): 1401-5.
