IMPACT

Process-of-care / Performance improvements

In primary care, multifaceted interventions in VISN 19 & 20 have included point of care reminders (both computerized and paper), pharmacist-run lipid clinics, audit and feedback, and order templates. All interventions piloted in VISN 20 have demonstrated moderate impact in specific process improvements:

• LDL-c measurement
• Lipid lowering agent use
• # of patients at LDL-c goal
• Overall mean LDL-c values

Morbidity performance improvements

Observations between September 1999 and September 2001 have indicated a 10% reduction of mean LDL-c values in VISN 20. Clinical trial extrapolations suggests that there has been a 17% reduction in adverse cardiac events. Untreated rates of major coronary events among these patients are estimated at approximately 5% per year, so that over a year, approximately 750 veterans might experience a major coronary event. Our work may have contributed to the overall reduction in LDL-c levels that translates into a commensurate reduction of approximately 75 major coronary events in VISN 20 between 1999 and 2000.

Mortality performance improvements

Since we have found that patients without a LDL-c measurement had higher hospitalization rates and lower survival, increasing the rate of LDL-c measurements in VISN 20 have subsequently decreased mortality rates in IHD patients.

The 17% reduction in major cardiac events leads to projections of 10,000 lives saved over 20 year period of time.

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CONTRIBUTIONS

Contributions to VA activities

IHD QUERI has been intensively involved in partnering with the Office of Quality and Performance (OQP), Patient Care Services (PCS), and the Office of Information (OI), under the direction of the Deputy Under Secretary for Health, since April 2003 to support implementation of the 10 Cardiac Care Initiatives. We are tasked with monitoring outcomes and process changes in major efforts to improve cardiac care in VHA. We have participated in weekly meetings/conference calls between the four offices involved in this effort: ORD (chiefly IHD QUERI, but also represented by Neil Thakur); OQP; PCS; and OI. IHD QUERI has been involved in the analysis and reporting of the data collected.

In addition to these products of intense consultation and joint activity, we have also accomplished the following:

• Prior to the initiation of the Cardiac Care Initiative, Dr. Fihn chaired a committee of national experts to review the report of the external evaluation of cardiac care in VHA, resulting in several significant changes to the report. (November 2002 to March 2003)
• Responded on a very rapid turn-around to a request from OQP to assess the degree to which the VA/DoD guidelines for non-ST elevation myocardial infarction (NSTEMI and acute coronary syndromes) corresponded with newly released guidelines from the AHA/ACC (February 2003).
• Collaborated and supported the work of OQP in proposing new Performance Measures in the area of cardiac care by conducting rapid literature reviews and syntheses, and assisting in the construction of measures (May-June 2003).
• Assisted PCS in developing criteria for assessing the completeness and quality of VISN and facility plans submitted in response to a directive issued in April 2003 (May-June 2003).
• Reviewed all the VISN and facility plans for improving care of AMI and Acute Coronary Syndromes (August 2003).
• Provided staff support to a national review committee to review VISN and facility cardiac care plans, chaired by Dr. Peter Almenoff (Program Director for Pulmonary and Critical Care in VHA) (August 2003).
• Participation and presentations at Dr. Robert Jesse’s Time is Life conference by several IHD QuERI Executive Committee Members (Stephan Fihn, Anne Sales, and John Rumsfeld) (February 2004).
• Led the development of, and are now leading the national implementation of, CART-CL (Cardiac Assessment Reporting and Tracking System for Cath Labs). CART-CL is the national VA cath lab data repository and reporting system. This has included software application development, data repository development, integration with CPRS, and collaboration with cardiologists across the VA to install and initiate clinical use of CART-CL. Furthermore, there is ongoing collaboration with ACC-NCDR to have CART-CL certified and allow participation of all VA cath labs in the widely recognized ACC-NCDR quality improvement program. (Drs. Fihn, Rumsfeld, Sales, Larsen, and Jesse.
• Involvement in the National Workload Measurement group, commissioned by the Under Secretary, to develop methods for capturing specialist workload in the cath lab. Dr. Rumsfeld participated in weekly calls with this group, and made modifications to CART-CL to ensure workload capture. (February 2004-January 2005).
• Ongoing work to monitor implementation of cardiac care improvement plans in the VISNs and facilities. Reports have been given to Dr. Jesse (National Program Director for Cardiology, PCS) and feedback from the field has been shared with Roxane Rusch of OQP. Monitoring is ongoing. (July 2004 ongoing).
• Reports of risk adjusted mortality outcomes for VA patients with AMI were presented to representatives of PCS (July 2004), OQP (September and November 2004), and the Deputy Under Secretary for Health (November 2004) to update and improve the risk models used in the external review. Risk adjusted process outcomes, including rates of cardiac catheterization, PCI and CABG, have also been developed. We continue to work closely with OQP in analyzing the EPRP data. (July 2004-ongoing).
• Dr. Sales was co-chair, with Dr. Catarina Kiefe, of the VA State of the Art conference on implementation. Several recommendations were made for VHA to consider in moving towards a more flexible approach to adopting evidence based practice. A special issue of the Journal of General Internal Medicine will feature papers from this conference. (August 2004).
• Dr. Sales had a lead role in coordinating the Guide to Implementation Research, published on the QuERI web site in August 2004. The Guide has been used by researchers planning proposals that incorporate principles of implementation research.
• Ms. Pineros and Ms. Wagner, working with Dr. Sales, conducted an evaluation of the dissemination of national patient education materials for the Time is Life initiative, to foster discussions between providers and patients about planning in the event of an AMI. Approximately $750,000 were spent producing and disseminating these materials. The report of the evaluation has spurred consideration of more effective approaches to getting the materials in the hands of patient educators at each site.

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Consultation efforts

Consultation has continued through the development and implementation of CART-CL nationally. Drs. Rumsfeld and Larsen are leading the clinical consultation to all 75 VA cath lab sites.

CLINICAL PRACTICE PRODUCTS

Clinician Education Materials

In VISN 23, written educational materials were provided to primary care providers in each facility. These materials provided up-to-date information on lipid management for IHD patients with low high density lipoprotein cholesterol (HDL-c).

Dr. Timothy Wilt, under the direction of the IHD QuERI Research Coordinating Center , performed a systematic review of lipid treatment and LDL-c threshold to try to answer the question of what should be the LDL-c goal for treatment in patients with IHD. The results of this systematic review are in press with Archives of Internal Medicine and should be published within the next 3 months.

Dr. Stephan Fihn was an author in the development of the ACC/AHA/ACP-ASIM guidelines for patients with chronic stable angina (Gibbons, et al. 1999).

Patient education materials

We have completed a pilot of the Pfizer-Parke Davis Close to the Heart patient education program among 420 high risk patients in VISN 20 (VA Northwest Network) in an effort to:

• promote healthier lifestyles and behavior change among high risk patients and
• reduce secondary risk of recurrent major cardiac events.

Outcomes were generally positive, and 75% of patients participating in the program expressed satisfaction and a perception that they had made lifestyle changes that were beneficial.

Other clinical practice support tools

• One of the IHD-QuERI’s Contributions to VHA operations is the implementation of two National Lipid Clinical Reminders that have been available in CPRS since May 2002. These reminders are designed to improve adherence to secondary prevention guidelines for lipid management in patients with IHD. The first reminder identifies patients with a diagnosis of IHD who do not have a current LDL value (within the past 12 months) and the second reminder identifies IHD patients whose current LDL values are above the VHA guideline recommended level of 120 mg/dL.
• The second phase of the National Lipid Clinical Reminders , reporting reminders to populate national databases at Austin , is due for release to the field February 14, 2005 (this was significantly delayed from the original planned release date in late 2003). We will work collaboratively with Mental Health QUERI to evaluate the completeness of the data in the national databases. Ideally, these databases could be used for facility and VISN level, as well as national, quality improvement.
• The members of the IHD QuERI Executive Committee including Robert Jesse, Karl Hammermeister, John Rumsfeld and Ken Morris participated in the development and update of the VA/DoD IHD guidelines (May-June 2003).
• The IHD QuERI Research Coordinating Center , in addition to consulting with EPRP to develop the abstraction tool for patients with ACS, also consulted with OQP in the development and revision of the 2003-2004 IHD performance measures.
• CART-CL has been fully developed and tested, and is now being implemented nationally. Ultimately, CART-CL will be used in all VA medical centers with catheterization facilities. Current active sites include Denver , Portland , West LA, Little Rock , Charleston , Atlanta , Tucson , and Durham . An additional 25+ sites are in the initial stages of implementation. Feedback from beta testing has been overwhelmingly positive, with input that CART-CL is time saving, improved clinical care through standardized documentation/communication, and through the national collaboration toward a single database and quality improvement program. To date, well over 50 VA cardiologists have utilized the system, generating >1500 procedure reports. Drs. Jesse and Rumsfeld continue to work toward VA participation in the ACC-NCDR.
• Dr. Sales has developed an Assessment of Organizational Readiness Tool to be used by clinicians to determine how prepared they are to start a evidence-based quality improvement intervention in their facility. It is currently being used as part of the assessment of implementation of cardiac care plans, and in an unrelated quality improvement collaborative to improve ICU care in VISN 23.
• ATHENA DSS is an automated decision support tool that makes a hypertension clinical practice guidelines available to clinicians as patient-specific recommendations during clinic visits. This tool combines hypertension guideline knowledge-base, with individual patient clinical data, to generate recommendations that can be displayed in a pop-up window in CPRS-GUI: ATHENA Hypertension Advisory. It has been made available at three medical centers: Palo Alto, San Francisco and Durham and is due to expand to VISN 1, VISN 21, and VISN 20 in calendar year 2004.

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RESEARCH PRODUCTS

Findings

Secondary prevention

• A large proportion of patients did not undergo LDL-c measurement in VISN 20. This lack of testing prevents risk stratification and guideline implementation (Sloan et al. 2001).
• The greater than 40% of patients who did not undergo LDL-c measurement had 5% higher hospitalization rates and 36% worse survival than patients who did undergo lipid measurement (Ho et al., 2003).
• A significant number of patients with IHD who were at high risk for an AMI and had indications for cardioprotective medications did not receive them until after their AMI (Miller et al., 2003).
• The patients who do not receive guideline recommended care for cholesterol management in VISN 20 are more likely to have a history of substance abuse, have a recent visit to the mental health clinic, have uncontrolled hypertension, and do not receive other guideline recommended treatments for IHD (Kopjar et al., 2003).
• 71% of patients in VISN 20 who were given a prescription for a lipid lowering medication were still taking their medication 18 months later (Kopjar et al., 2003).
• Provider self-report of use of the IHD lipid clinical reminders was positively and significantly associated with patient attainment of guideline-recommended goals (Sales final report SDR # IHT 01-040).

Acute phase care

• VHA patients have more coexisting conditions than Medicare patients. Nevertheless, after controlling for these conditions, there was no significant differences in mortality between VHA and Medicare patients, suggesting a similar quality of care for AMI patients (Petersen et al., 2000).
• VHA patients with mental illness were marginally less likely than patients w/o mental illness to receive diagnostic angiography, but no less likely to receive revascularization procedures or medications known to benefit patients after AMI (Petersen et al., 2003).
• Regionalization policies appear to result in underuse of angiography in the VA health care system as compared with Medicare (Petersen et al., 2003).
• Since 1996, there has been a decrease in the rate of use of revascularization procedures in VHA (Maynard and Sales, 2003).
• After patients have experienced an ACS episode, there is a strong association with h/o depression and both angina burden and worse health status (Rumsfeld et al., 2001).
• Elements of clinical integration are associated with transfer of patients to other facilities, an important process in the care of ACS patients in the VHA (Sales et al., 2005).
• The use of drug eluting stents has increased dramatically over the last three years within VHA (Maynard et al., under review 2005).
• Risk-adjusted mortality for AMI patients varies across VISNs in FY04, but not significantly. Rates remain similar to those found in the external evaluation of cardiac care (14% overall) (Maynard et al. in preparation 2005).
• However, much of the relatively high mortality for AMI patients in VHA is due to the presence of a large cohort of patients who experience AMI as inpatients while hospitalized for another diagnosis. Mortality in this cohort is 28% while it is 10% for patients admitted with AMI as their presenting diagnosis. (Kopjar et al. in preparation 2005)

Chronic management of IHD

• Depression is associated with significantly more physical limitation, more frequency of angina, less treatment satisfaction, and lower perceived quality of life in outpatients with IHD (Spertus et al., 2000).
• SAQ scores are independently associated with 1-year mortality and ACS among outpatients with coronary disease and may serve as a valuable role in risk stratification of these patients (Spertus et al., 2002).
• Current angina symptoms and aspects of physician communication are independently associated with treatment satisfaction after ACS (Beinart et al., 2003).
• Many patients with frequent episodes of chronic stable angina appear to be receiving inadequate anti-anginal regimens in terms of both number of agents prescribed as well as dosage prescribed (Wiest et al., 2004 in press).

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Databases

• CCFCS database : This db is a rich registry of clinical data for patients who are admitted to VHA with a diagnosis of ACS (unstable angina or AMI).
• National Lipid Clinical Reminders Reporting Database : Reminder reports can be created for patients identified in the reminder definition of either clinical reminders or reporting reminders. Although clinical reminders are developed for clinical use, they may also be used in preparing reports. In contrast, reporting reminders are developed solely for the purpose of preparing reports, or aggregating and extracting data. This distinction is useful, because the applicable and due cohorts defined in reminders for clinical use often are not ideal or appropriate for reporting purposes. For the IHD national reminders, facility-level data will be transmitted to the database each month. All IHD patients with a clinic encounter at a qualifying VA clinic in the prior month will be included in the monthly extract. The data will include reminder-applicable and due counts for each of the IHD clinical and reporting reminders; utilization counts for each clinical reminder dialog element; and the number of IHD patients at each facility on lipid lowering agents, with a current lipid measurement, and in each LDL-c category. The national reporting reminder database will include data for selected national clinical and reporting reminders aggregated at the facility level. Data transmission to the national database is not mandatory at this time, therefore data will only be available for facilities that have elected to use the reminder transmission software and will not be generalizable to other VA facilities. Presently, the Reporting Database is being tested. The release date for the national VistA patch is 2/14/2005, with a 45 day period following while facilities install it. Note that the full installation, mapping, and reporting is not mandated. We will evaluate the use of these reporting reminders.
• The ACQUIP project (Ambulatory Care Quality Improvement Project, Fihn, PI) has developed a Data Repository, making the data from this very large, multi-site trial available on an ongoing basis for current and future investigators. This is a very rich data source of clinical and administrative data that has been used, and continues to be used, to investigate a number of different clinical topics.

Measures and methods

• The Organizational Readiness Assessment Tool is a measure that has been developed based on the data collected during the Lipid Study in assessing the barriers and facilitators in implementing lipid interventions in VISN 20. This tool has been tested with a small group of providers in VISN 19 and will undergo further testing with providers as interventions develop nationally in the acute phase of care for ACS patients.
• The Tracking Database is also a tool that was developed from work with Clinical Reminder evaluation in VISN 19. This tool tracks information that is used while intervention activities are taking place to help elucidate process measures that are often overlooked when clinical interventions are being implemented.
• National IHD Lipid Clinical Reminders are a method of intervention development. We collaborated with the Office of Information System and Design and Development (SDD) Health Data Systems Group to develop two national electronic clinical reminders, released nationally in May 2002. Extensive information about the development of these national reminders, a major product of the Lipid Study, is available upon request from the PI, Anne Sales. We conducted an evaluation of the effectiveness of the national IHD reminders in VISN 19 between September 2002 and September 2003, with three intervention sites (eastern half of VISN 19) and four control sites (western half).

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