QUERI – Quality Enhancement Research Initiative

Improving Safety and Quality through Evidence-Based De-Implementation of Ineffective Diagnostics and Therapeutics

Puget Sound, WA

View program fact sheet

We know a lot about how to implement interventions to improve the quality of healthcare. But how do we effectively de-implement care that is low-value or contraindicated, and what are the dynamics and potential unintended consequences of doing so? The Improving Safety and Quality QUERI program helps answer these question by:

• Working with key operational leaders to identify and prioritize diagnostics and therapeutics that are ineffective, contraindicated, or of low value to Veterans – and developing de-implementation strategies that work in concert with operational strategies and policies;
• Testing the effectiveness of de-implementation strategies to reduce ineffective, contraindicated, or low-value diagnostics and therapeutics;
• Developing the science of de-implementation by understanding how de-implementation efforts affect patients’ and clinicians’ experiences of care, and how organizational context affects de-implementation efforts; and
• Informing dissemination of effective strategies by assessing the budget impact of de-implementation strategies.

Findings and Impact(s):

DISCUSS COPD. Preliminary analysis shows that among a cohort of 156 patients, QUERI investigators recommended stopping inhaled corticosteroids for 107 (69%) Veterans. Of the 107 patients for whom recommendations were made to discontinue inhaled corticosteroids, 104 (97%) were accepted. A total of 160 additional recommendations were made, including inhaled corticosteroid titration orders, albuterol orders, and repeat pulmonary function test orders. Of these, 90% (n=144) were accepted by their primary care providers.

QUERI investigators are conducting provider surveys, and patient and provider interviews to understand their experience of the proactive e-consult: awareness of harms from inhaled corticosteroid use and availability of alternative therapy; and patients’ perspectives on changing their COPD therapy. The response from primary care providers to the proactive e-consult has been overwhelmingly positive. De-implementing ineffective diagnostic and therapeutic practices has the potential to improve the quality and safety of care for Veterans, improve the value of care, and in some cases, improve timely access to care. In addition, the Lung Nodules project suggests that alternative strategies beyond educational interventions may be needed to encourage radiologists to commit to including a recommendation of “no additional follow-up is needed.”

Principal Investigators: David Au, MD, MSc (David.Au@va.gov); Christine W. Hartmann, PhD (Christine.Hartmann@va.gov); Christian Helfrich, PhD, MPH (Christian.Helfrich@va.gov)

Operational Partners: Pharmacy Benefits Management Services, Office of Specialty Care Services, and Geriatrics and Extended Care