January 2009

In This Issue:

• 2008 QUERI National Meeting
• QUERI Center Updates
• Recent QUERI Publications

2008 QUERI National Meeting: Connecting Research and Patient Care

VA's Health Services Research & Development Service (HSR&D) Quality Enhancement Research Initiative (QUERI) National Meeting was held from December 10-12, 2008 in Phoenix, AZ. The QUERI program was created to improve the quality of healthcare for veterans by implementing research findings into routine clinical practice. More than 250 researchers, clinicians, and policy makers participated in plenary sessions, workshops, and poster sessions to focus on the vital partnership between VA Research and Operations in facilitating and systematizing the implementation of evidence-based interventions into routine clinical care. The meeting also allowed the QUERI Centers to share valuable lessons learned that will save time and costs in future implementation efforts. Each of the QUERI Centers focuses on a different disease/condition prevalent among veterans: chronic heart disease, diabetes, HIV/Hepatitis, ischemic heart disease, mental health, polytrauma and traumatic brain injury, spinal cord injury, stroke, and substance use disorders.

The QUERI National Meeting marked QUERI's tenth year as a crucial part of VA's quality improvement efforts and several remarkable achievements were noted. For example, QUERI investigators developed a quality improvement project to increase influenza vaccination rates among veterans with spinal cord injury that was implemented in 23 VA Spinal Cord Injury Centers, improving vaccination rates for all age groups. QUERI investigators also have increased rates for alcohol abuse screening, as well as HIV testing. And QUERI developed an evidence-based collaborative approach to depression management that has proven successful in the VA healthcare system.

QUERI has emerged as a leader in Implementation Science and an important program for improving healthcare for veterans. QUERI will continue to work with its partners to advance healthcare for veterans, particularly VA's Office of Quality and Performance, Patient Care Services, Office of Nursing Services, and the Office of Information and Technology.

To view abstracts and/or presentations from the QUERI National Meeting, go to http://www.hsrd.research.va.gov/meetings/QUERI08/.

QUERI Center Updates

Reducing Hospital Readmissions for Veterans with Chronic Heart Failure

Chronic Heart Failure QUERI (CHF-QUERI) has been focusing on early follow-up after discharge to reduce hospital readmissions for veterans with CHF. In conjunction with the Institute of Healthcare Improvement's '5 Million Lives Campaign' - a national effort to reduce preventable deaths in U.S. hospitals - and support from VA Patient Care Services and the Office of Quality Performance, data are being examined for all VA facilities to understand their current status of care for heart failure and discharge policies for veterans hospitalized with heart failure. Impact of early follow-up with cardiology or another outpatient provider on readmissions following a heart failure admission has been seen to be associated with reduced readmissions for heart failure but increased admissions for any cause. For more information about this project, please contact Anju Sahay, PhD, CHF-QUERI Implementation Research Coordinator, at anju.sahay@va.gov.

Fostering Collaborative Leadership for Chronic Heart Failure Care

With the support of a $300,000 grant from the Robert Wood Johnson Foundation, the CHF-QUERI through its Heart Failure Network has collaborated with Douglas Wholey MBA, PhD and Joanne Disch PhD, RN, FAAN from the University of Minnesota. They are studying how collaborative leadership between clinicians and nurses create a strong team in environments where individuals effectively work together and coordinate their care for heart failure patients. For further information contact Anju Sahay, PhD, CHF-QUERI Implementation Research Coordinator, at anju.sahay@va.gov.

Diabetic Foot Ulcer Treatment and Amputation Prevention

Diabetes Mellitus QUERI (DM-QUERI) investigators, Gayle Reiber, PhD and Gregory Raugi, MD developed a wound care program for improving healing rates and reducing amputations among veterans with diabetes. Program components included: wound care team education and training, standardized good wound care practices, CPRS (computerized patient record system) wound care template, case management, consultation via telemedicine, and emergency assistance. In assessing the study, the intervention group had significantly shorter times to healing and a greater percentage of healed ulcers for the time periods examined (2003 and 2007). The amputation rate decreased from 23.4% in 2003 to 12.5% in 2007. For further information, contact Dr. Reiber at gayle.reiber@va.gov.

Increasing Risk-Based HIV Screening and Testing

HIV/Hepatitis-QUERI has recently completed its VISN QI project, which successfully demonstrated that an intervention package that includes a strong organizational component and provider activation, social marketing, and academic detailing as well as periodic audit/feedback reports can be utilized to increase HIV testing among persons with known risk factors in the primary care setting. In particular, investigators found that the rate of overall HIV screening increased from 13-23% to 50-74% from baseline to year one across the four study stations in VISN 22, while no change in HIV screening was found at the control station. Furthermore, the rates of HIV testing remained stable during the second year of the intervention, when the direct involvement of the study team was greatly lessened and responsibility for program maintenance was largely transferred to local clinical staff.¹

The recently funded Multi-VISN QI project expands the scope of this project into VISN 3 and VISN 16. This project will:

• Determine the generalizability of this intervention to these VISNs,
• Evaluate different modes of implementing the intervention,
• Assess the costs of implementation, and
• Examine the effectiveness of the intervention.

Particular consideration will be given to the impact of pending VA guidelines that will modify the processes for HIV testing within the VA now that the legal requirement for obtaining written informed consent for HIV testing has been repealed. Although this project specifically targets high-risk patients for HIV testing, the lessons learned will provide insights into routine testing as well. For more information about this project, please contact Dr. Herschel Knapp at Herschel.Knapp@va.gov.

Improving Access and Equity for HIV and Hepatitis Treatment

HIV/Hepatitis-QUERI has added a new strategic goal to their mission - Improve Access and Equity - reflecting their efforts to address inequitable access and health disparities in the two diseases. As HIV and HCV (hepatitis C virus) occur more frequently among racial and ethnic minorities, persons with low-income, the unstably housed, substance users and otherwise disadvantaged populations, the importance of equitable access to healthcare services is highlighted.^2,3 Evidence suggests that lack of access might led to poorer outcomes for vulnerable populations and that gaining access to medical care may make a difference for persons with HIV for a variety of outcomes, including mortality and quality of life.^4,5

VA Patient Safety Surveillance Network for Cardiac Catheterization Devices

Ischemic Heart Disease QUERI (IHD-QUERI) investigators at the Cardiovascular Assessment, Reporting and Tracking System (CART) Coordinating Center and the VA National Center for Patient Safety are formally collaborating with the FDA (Food and Drug Administration) to establish CART as a sentinel device surveillance/patient safety network. CART is the national reporting software, data repository, and quality management system for all VA cardiac catheter labs. A specific data field was added in 2006 to track device-related adverse events (DAE's) for percutaneous coronary intervention (PCI). The CART Coordinating Center audits DAE's monthly and also holds monthly calls with FDA and the VA National Center for Patient Safety to discuss adverse events. Active surveillance is critical because devices receive FDA approval based on use in very controlled environments. Complications, such as stents becoming stuck during insertion, often emerge when the device begins routine use in "real-world" settings. In 2008 alone, the FDA approved two new cardiac stents that CART began tracking immediately. Because it tracks complications in real time, CART can identify device problems early and improve patient safety. This program serves as a model of collaboration between QUERI, VA operations, and key organizations such as the FDA. For more information, please contact John Rumsfeld at John.Rumsfeld@va.gov or Tamara Box at Tamara.Box@va.gov.

Using a Blended Facilitation Model to Implement Evidence-Based Practices

A new Mental Health QUERI (MH-QUERI) study, "Blended Facilitation to Enhance Primary Care Mental Health (PC-MH) Program Implementation," will test the effectiveness of a network level facilitation model. QUERI initiatives to advance Implementation Science and promote evidence-based practices (EBPs) have found that effective implementation often requires a program with multiple components, tailored to local settings, a mix of strategies, and stakeholder involvement. Dr. JoAnn Kirchner and other VISN 16 investigators developed and applied an efficient network-level facilitation model that uses a network-based internal facilitator and an expert external facilitator to implement PC-MH integrated care programs. VISN 16's experience with this blended facilitation model has been promising. Although the VISN does not have patient-specific outcomes yet, preliminary evidence indicates the program is effective and efficient, with participating sites reporting a 44% decline in consults to specialty Mental Health Clinics.

The new QUERI study will implement and evaluate this blended facilitation model at selected primary care clinics. The study presents a unique opportunity to leverage and potentially optimize an important VA clinical initiative to enhance system impact. For more information about the Blended Facilitation study, contact JoAnn Kirchner, MD, at JoAnn.Kirchner@va.gov.

Assessing Organizational Change Readiness

The Polytrauma and Blast-Related Injuries (PT/BRI) QUERI will be using an instrument for examining organizational readiness to implement a change initiative, especially practice changes. The Organizational Change Manager (OCM) uses a Bayesian model to predict and explain the likelihood of successful implementation based on the state of specific organizational factors. It has been tested in more than 500 non-VA projects from which there is evidence of predictive validity. The PT/BRI QUERI is recruiting other QUERI Centers to collaborate in testing the feasibility and utility of the OCM in implementation projects. The PT/BRI QUERI will provide a toolkit for use of the OCM, including: the survey, the analytic algorithm for the OCM scores, a guide to administer the OCM as recommended by the developers, and a handbook with the developers guidelines and recommendations for use of the OCM results in practice. Participating teams should be willing to administer the OCM according to the recommendations of the developers, which include administration at baseline, project start, and several additional time points. Further, teams will provide the PT/BRI QUERI with feedback about the administration and experience using the OCM. For more information, contact Dr. Carmen Hall at carmen.hall@va.gov.

MyHealtheVet as a Means to Promote Evidence-Based Care

The Spinal Cord Injury (SCI) QUERI, along with the Mental Health, HIV/Hepatitis and Stroke QUERIs, and HSR&D Resource Centers VIReC and HERC, have joined with VA's MyHealtheVet (MHV) to identify opportunities to increase the use of evidence-based care and improve outcomes among veterans. MyHealtheVet is a web-based system that allows veterans to access, store, and track health information. In a working group held during the QUERI National Meeting (12/08), QUERI investigators and MHV staff gave a series of presentations about MHV system functionality and current MHV-related research projects. Following the presentations, working group participants broke into smaller groups to explore two possible MHV research scenarios: (1) the use of data contained within the MHV system, and (2) the use of MHV for intervention studies. Working group participants concluded that each of these scenarios presents some unique issues.

First, access to MHV data is not possible unless the veteran delegates authority to access their data; however, the MHV program office recently developed a mechanism by which veterans can perform such delegation. Should a veteran delegate authority to a research team, then it would be possible to use their MHV data as part of a study. In the second scenario, the group drew an important distinction between studies that use MHV to deliver an intervention, and those in which the MHV system is itself the intervention. For example, an educational intervention for blood pressure management could be delivered through MyHealtheVet. Alternatively, veterans could be randomly assigned to either receive the intervention through MyHealtheVet or through a more traditional route such as a clinic visit. In the latter example, the study would determine whether MyHealtheVet was as, or more effective for care delivery than the alternative strategy. Participants in the working group plan to continue collaborating in an effort to move this agenda forward. They welcome the involvement of others with similar interests. For more information, please contact Dr. Fran Weaver at frances.weaver@va.gov.

Stroke-QUERI and OQP Collaborate to Measure the Quality of Stroke Care

Stroke QUERI is working with VA's Office of Quality and Performance (OQP) on a Stroke Special Project to measure the quality of stroke care within the VA system nationwide. The primary objective of this project is to measure and feed back to VA facilities their performance on the Joint Commission's stroke quality indicators among 5000 veterans admitted with an acute ischemic stroke to a VA medical center in FY07. The secondary objectives are to evaluate stroke risk factor management in the year pre-stroke and to assess risk factor management and rehabilitation care delivery in the first six months post-stroke. This project will provide benchmark data about VA performance for acute inpatient stroke care. In addition, it will identify important evidence-practice gaps in acute stroke care and in pre- and post-stroke risk factor management. These data also will be used by Stroke QUERI to: develop and test a stroke quality improvement network, prioritize future planned projects to improve VA stroke care, and stimulate the field to work proactively to improve VA stroke care. The data collection is complete and expected to be released this year. For more information, please contact Dawn Bravata, MD, Stroke-QUERI's Co-Clinical Coordinator, at dbravata@iupui.edu.

Stroke Quality Improvement Project

Stroke QUERI has launched the Stroke Quality Improvement Network (SQuINt) - a network of thought leaders dedicated to improving and implementing local changes in the quality of stroke care within the VA system. One of the first major activities for this group will be helping the field navigate the soon to be released Office of Quality Performance (OQP) FY07 stroke care data. For more information about SQuINt, contact Patricia Banks at patricia.banks@va.gov or Laurie Plue at lplue@iupui.edu.

Improving Management of Alcohol Misuse Nationwide

Alcohol screening with brief alcohol counseling is the third most important prevention priority for the U.S., based on clinically preventable disease burden and cost-effectiveness of the intervention. To date, the VA is the first and only integrated healthcare system to achieve sustained implementation of both alcohol screening and documented brief alcohol counseling for follow-up of patients who screen positive for alcohol misuse. Through collaborative efforts between VA's Office of Quality and Performance (OQP), SUD-QUERI and other clinical partners, VA implemented routine alcohol screening with the AUDIT-C (Alcohol Use Disorders Identification Test) in 2004, achieving a current screening rate of 91%. In 2006, SUD-QUERI collaborated with OQP to develop new measures of monitoring brief alcohol counseling, defined as documented advice to reduce or abstain from drinking and feedback linking drinking to health, through medical records review. Continued collaboration with OQP led to development of a national performance measure for brief alcohol counseling which was implemented in FY08.

Prior to implementation of the performance measure, SUD-QUERI created a CPRS clinical reminder for brief alcohol counseling designed to offer decision support, provider education, assessment and risk stratification of patients, and medical record documentation of the intervention. The clinical reminder was initially tested at a single VA site and later evaluated in an 8-site facility. After updating the clinical reminder to be consistent with the FY08 performance measure for brief alcohol counseling, it was recommended for use nationally and disseminated through VA's CPRS (computerized patient record system) to all medical centers in January of 2008. Since dissemination, national medical record review (EPRP) shows rates of documented brief alcohol counseling have steadily increased (10% the year prior to the performance measure to 43% Jan - March 2008 and 50% April-June 2008).

SUD-QUERI continues to consult on efforts to implement national roll-up of data on these two performance measures to improve the timeliness and reliability of facility-level performance monitoring and to facilitate evaluation of future quality improvement efforts. For more information, contact Katharine Bradley, MD MPH at Katharine.bradley@va.gov.

References

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2. Andersen R, Bozzette S, Shapiro M, et al. Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. HCSUS Consortium. HIV Cost and Services Utilization Study. Health Services Research 2000;35:389-416.
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5. Keruly JC, Moore RD. Immune status at presentation to care did not improve among antiretroviral-naive persons from 1990 to 2006. Clinical Infectious Diseases 2007;45:1369-74.

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