BACKGROUND/RATIONALE:
Ischemic heart disease affects at least 500,000 veterans using the Veterans Health Administration each year. Treatments to prevent recurrent disease have been demonstrated in many randomized clinical trials. The goal of this project was to implement these best practices in secondary prevention in several Veterans Administration Medical Centers.
OBJECTIVE(S):
The objectives of the Translation Plan to Improve Lipid Management for IHD Patients were:
1. To improve the health of veterans with IHD through increases in: (a) lipid measurement; (b) appropriate use of lipid-lowering agents; and (c) the numbers of patients with LDL levels at the VA guideline-recommended goal of less than 120 mg/dL;
2. To evaluate further and refine the lipid management interventions from the LMMS pilot project in VISN 20;
3. To develop and evaluate an updated electronic clinical reminder system as a lipid intervention strategy.
METHODS:
In the first part of the study, clinicians who had participated in prior interventions were interviewed to learn what the major barriers and facilitators to the interventions had been. These interviews were conducted using structured interview protocols, and content analysis was used to assess and categorize themes. In the second part of the study, the information from these interviews was used to design new interventions, particularly electronic clinical reminders in the Computerized Patient Record System in VHA. These were then deployed in several medical centers and evaluated. Patient level data including laboratory and pharmacy records were used to assess process and outcomes.
FINDINGS/RESULTS:
Significant barriers to implementing best practices included insufficient provider time to provide preventive care during routine visits; lack of senior leadership buy-in to support interventions; and insufficient planning of the interventions to overcome barriers encountered during the course of the interventions. On deployment of the reminders, the comparison between the intervention and non-intervention sites showed that non-intervention sites had higher rates of LDL-c measurement and patient attainment of guideline-recommended goals. In addition, non-intervention sites improved more than intervention sites in achieving guideline-recommended goals. However, provider self-report of use of the IHD lipid clinical reminders was positively and significantly associated with patient attainment of guideline-recommended goals.
IMPACT:
In order to reap full benefit from the large investment it has made in developing the software to support state of the art electronic reminders, VHA should also invest significantly in training, support, and interventions to change provider culture about reminder use. Such interventions would require considerable support from senior leadership, as well as careful and concerted use of clinical champions who would not only support the clinical best practice, but also the use of reminders to achieve these practices. In addition, expanding this study to a wider range of sites would provide a greater degree of generalizability.
PUBLICATIONS:
Journal Articles
- Sharp ND, Pineros SL, Hsu C, Starks H, Sales AE. A qualitative study to identify barriers and facilitators to implementation of pilot interventions in the Veterans Health Administration (VHA) Northwest Network. Worldviews on evidence-based nursing / Sigma Theta Tau International, Honor Society of Nursing. 2004; 1(2): 129-139.
- Kopjar B, Sales AE, Piñeros SL, Sun H, Li YF, Hedeen AN. Adherence with statin therapy in secondary prevention of coronary heart disease in veterans administration male population. American Journal of Cardiology. 2003; 92(9): 1106-8.
- Miller RR, Li YF, Sun H, Kopjar B, Sales AE, Piñeros SL, Fihn SD. Underuse of cardioprotective medications in patients prior to acute myocardial infarction. American Journal of Cardiology. 2003; 92(2): 209-11.
- Kopjar B, Sales AE, Piñeros SL, Sun H, Li YF, Hedeen AN. Comparison of characteristics of patients with coronary heart disease receiving lipid-lowering therapy versus those not receiving such therapy. American Journal of Cardiology. 2003; 91(11): 1352-4.
- Ho PM, Maynard C, Starks H, Sun H, Sloan K, Sales A. Outcomes in patients with coronary heart disease who do not undergo lipid testing. American Journal of Cardiology. 2003; 91(8): 986-8, A7.
