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Prior Impacts of Disease-Focused QUERI Centers

* The disease-focused QUERI Centers are no longer in operation and have been replaced by QUERI interdisciplinary programs.

Since 1998, VA HSR&D's Quality Enhancement Research (QUERI) had been working to implement evidence-based research interventions into clinical care in the most effective and efficient way possible. As QUERI continues to help the VA healthcare system improve care for Veterans, the program has evolved from ten Centers with a focus on a specific disease or condition to interdisciplinary programs that focus on achieving updated VHA national priority goals through cross-cutting partnerships and specific implementation strategies. This evolution would not have been possible without the tremendous work done by the QUERI Centers. Here are some of their most important contributions to our Veterans, the VA healthcare system, and implementation science.

Chronic Heart Failure (CHF) QUERI

CHF-QUERI has made significant contributions in the areas of safety, hospital readmissions, use of life-prolonging therapy, as well as the de-implementation of unnecessary cardiac imaging. A few specific impacts include:

Reducing Unnecessary Hospitalizations for Veterans with CHF: The Hospital-to-Home campaign (H2H) conducted by the Institute for Healthcare Improvement and the American College of Cardiology – and led by CHF-QUERI – resulted in a reduction in hospital days for 80 participating VA facilities. These efforts contributed to a decline in 30-day readmission rates (all-cause following a heart failure hospitalization) from 21% in 2010 to 18% in 2014. Across the VA healthcare system, H2H participation was associated with a reduction of 21,000 hospital days each year, which translates to cost savings of approximately $18 million per year.

Improving Safety Monitoring: Over the last 18 months VA's Pharmacy Benefits Management Services' Medication Use Evaluation Tracker (MUET) Program has been using an intervention developed by CHF-QUERI to improve the safety of aldosterone antagonists for Veterans with heart failure. This intervention includes sending local pharmacists a list of heart failure patients with a new prescription for an aldosterone antagonist. This intervention has been implemented nationally as part of the MUET Program.

Fewer Unnecessary Tests and Procedures: In 2015, CHF-QUERI investigators presented data on a randomized trial of a reminder to reduce inappropriate cardiac imaging. This reminder will reduce 30-40 inappropriate imaging studies per year for an estimated savings of about $10,000 at one VAMC. In its second year, it is expected to save even more, representing 60 fewer unnecessary studies. In addition, the wait-time for echocardiography has been reduced by two days as a result of opening up more space for appropriate studies.

Diabetes-QUERI

Diabetes-QUERI has made significant progress in a number of areas of critical importance to improving the health and care of Veterans with diabetes. A few specific impacts include:

Reducing Risk Factors for Type 2 Diabetes in Veterans: Diabetes-QUERI evaluated the VA Diabetes Prevention Clinical Demonstration Project that showed significant weight loss in pre-diabetic Veteran participants at both 6 and 12 months compared to participants in VA's MOVE! Weight Management Program. Informed by these findings, VA's National Center for Health Promotion and Disease Prevention (NCP) disseminated new MOVE! guidelines. In addition, Diabetes-QUERI continued its collaboration with NCP and Mental Health-QUERI in linking national MOVE! data to two mental health-related registries in order to examine the relationship between various mental health diagnoses and weight loss. Numerous manuscripts have resulted from this collaboration.

Development of Improved Performance Measures: Diabetes-QUERI created a novel performance measure that is aligned with the new VA/DoD Clinical Practice Guidelines for the Management of Dyslipidemia. This new measure is designed to create stronger incentives for prescribing statins in higher risk patients and reduced incentives for prescribing in lower risk patients. QUERI investigators also developed two different measures of under- and over-treatment for hyperglycemia, which represent substantial improvements over existing measures focused solely on over-treatment. These measures have been used successfully to identify VA facilities with consistently low rates of under- and over-treatment for hyperglycemia, as well as facilities with consistently high rates.

Major Contributions to Implementation Science: Diabetes-QUERI has contributed to further development of CFIR (Consolidated Framework for Implementation Research) methods and tools, and use of the CFIR continues to grow. More than 641 articles have cited the original article by Damschroder and colleagues (Implementation Science, 2009), and it is one of the top 5 papers accessed in the journal. The CFIR article also is in the 97th percentile of citations found in non-research sources (e.g., social media platforms, blogs, news outlets). The CFIR continues to be used internationally and in disciplines other than healthcare (e.g., education).

eHealth-QUERI

eHealth is an over-arching term inclusive of modalities that range from telehealth, secure messaging, and My HealtheVet, to mobile health (mHealth) applications. eHealth-QUERI has made significant advances in engaging Veterans and augmenting clinical practice through these and other virtual care modalities. A few specific impacts include:

Enhanced the Adoption and use of the My HealtheVet Patient Portal: eHealth-QUERI investigators compared My HealtheVet adoption (i.e., portal registration, authentication, and opt-in for secure messaging) and use (i.e., prescription refill and secure messaging) of the patient portal across 18 specific clinical conditions that are prevalent among Veterans and are of high priority to the VA healthcare system. Nationwide, 19% of Veterans registered for My HealtheVet, 11% refilled prescriptions via My HealtheVet, and 2% used secure messaging with their clinical providers. Results indicate that VA patients with HIV, hyperlipidemia, and spinal cord injury had the highest predicted probabilities of adoption, whereas those with schizophrenia/schizoaffective disorder, alcohol or drug abuse, and stroke had the lowest.

Increased Use of the Blue Button Feature on My HealtheVet: eHealth-QUERI investigators examined the effectiveness of training Veterans to use My HealtheVet to generate a summary of their VA healthcare taken directly from the computerized patient record system (CPRS), and then sharing this summary with their non- VA providers to improve co-managed care. Veterans in this study were able to generate a health summary of their VA care, with 70% being able to do so using only the paper and online materials. Veterans who received health summary training were far more likely than those who did not to share their VA health summary with their non-VA providers. Both patients and providers reported a positive impact of sharing their medical information with non-VA providers. eHealth-QUERI investigators also examined current perceptions and use of the My HealtheVet Blue Button feature among VA primary care team members, and used these insights to design a toolkit to promote integration and use of Blue Button in VA primary care settings.

Implemented Pre-visit Planning through the Secure Messaging Feature on My HealtheVet: eHealth-QUERI investigators implemented pre-visit planning through secure messaging as part of a two-phase implementation trial. Primary care team members were given an implementation guide, related training, and technical support, as well as the assistance of a pre-visit secure messaging champion who initiated secure message exchanges on behalf of the participating clinical teams. The champion sent messages to each patient who had access to secure messaging and also had a scheduled appointment in the upcoming two weeks. Patients were asked to respond to the secure message with three topics that they would like to discuss at their upcoming appointment. A total of 2013 pre-visit messages were sent to Veterans. Of the messages sent, 818 (41%) were read, and 231 (11%) Veterans replied with topics for discussion. Those topics were diverse, and ranged from medications to current pain levels to questions about healthcare coverage. Findings provide evidence for the use of pre-visit secure messaging to improve Veteran engagement and communication.

HIV/Hepatitis (HH) QUERI

HH-QUERI made tremendous progress in several key areas, including: better disease identification; improving linkage, retention,

and adherence to care; and reorganizing care for improved coordination and value. A few specific impacts include:

Nurse Rapid-Testing for Hepatitis C Virus in Substance Use Disorder Clinics: HH-QUERI investigators previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. HH-QUERI investigators have now successfully implemented rapid testing for hepatitis C virus (HCV) at six VA substance use disorders clinics.

Improving Linkage, Retention, and Adherence to Care: An algorithm created by HH-QUERI investigators allows Clinical Public Health and others to determine the timeliness with which Veterans newly diagnosed with HIV link to medical care, and evaluate the patient-, provider-, and facility-level variations in this linkage. Another HH-QUERI study has demonstrated a technology-enhanced method to HIV medication. The intervention involved patient use of tablet computers for pre-visit clinical assessments, plus tailored adherence support from an adherence care manager.

Reorganizing Care for Improved Coordination and Value: A study conducted by HH-QUERI investigators evaluated the cost effectiveness of new treatments for HCV, and worked to understand how to maximize treatment benefit when not all patients can be treated immediately. HH-QUERI investigators also partnered with VA Specialty Care Services (SCS) and Primary Care Services to provide evidence for telemedicine collaboration between specialists and generalists treating patients with HCV. Work on this project has provided the operational partners with qualitative data on HCV SCAN-ECHO (Specialty Care Access Network – Extension for Community Healthcare Outcomes) in the VA healthcare system and will contribute toward HCV quality of care data in the future.

Ischemic Heart Disease (IHD)-QUERI

Since its inception, IHD-QUERI has made significant contributions to improving the health and care of Veterans with Ischemic Heart Disease (IHD). A few specific impacts include:

Tracking the Use and Outcomes of VA Cardiac Catheterization Procedures: Working with VA Patient Care Services (PCS), the Office of Quality and Performance, and the Office of Information and Technology (OI&T), IHD-QUERI developed the Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL). CART-CL was developed to address the critical need for a systematic, national method for tracking the use and outcomes of diagnostic and interventional cardiac catheterization procedures among Veterans in the VA healthcare system – and to implement an associated national quality program. CART-CL has been successfully implemented in all VA cath labs, and is regarded as a model for clinical application development and implementation within the VA healthcare system. To further enhance CART-CL, IHD-QUERI investigators developed a method for data capture using an inter-active voice response (IVR) system through the CART-CL program. The IVR system automatically calls the patient to administer the health status measures at one and six months post-procedure. The ultimate goal is to have these data summarized in a personal health status report provided back to patients and providers to document symptom changes based on their self-report.

Improving Medication Adherence and Secondary Prevention Measures: IHD-QUERI investigators published findings from the "Multi-Faceted Intervention to Improve Cardiac Medication Adherence and Secondary Prevention Measures" study in JAMA Internal Medicine (Ho et al, 2014). This study tested a multi-faceted intervention to improve adherence to cardio-protective medications, such as clopidogrel and statins, in the year after an acute coronary syndrome hospitalization. The intervention had four components: 1) collaboration between pharmacists and clinicians, 2) study pharmacists working directly with the intervention patients, 3) patient education, and 4) automated medication refill reminder and education calls. Results showed a statistically significant improvement in adherence to cardiovascular medication in the Veterans who were enrolled in the intervention group compared to Veterans enrolled in the usual care group (89% vs. 74%, respectively).

Mental Health (MH) QUERI

MH-QUERI worked to support and enhance the implementation of evidence-based practices, as well as promising clinical practices that address high-priority system needs, for Veterans with mental health conditions. A few of their specific impacts include:

Improving Health of Veterans with Serious Mental Illness: MH-QUERI's work in the area of improving physical health treatment and outcomes for Veterans with serious mental illness (SMI) has culminated in several national impacts. Most importantly, MH-QUERI's past and current work in improving metabolic side-effect monitoring and management for Veterans taking antipsychotics informed the MIAMI (MIRECC Initiative on Antipsychotic Management Improvement) Project's national training conference, as well as two cyberseminars, to train VA clinicians on how to improve care in this area. This was a partnership involving VA's Office of Mental Health Services (OMHS), Employee Education System (EES), MH-QUERI, the VISN 16 South Central MIRECC, and the VISN 22 Desert Pacific MIRECC. MH-QUERI supplemented these educational activities with quality improvement tools and strategies from previous MH-QUERI projects, and by creating a MIAMI Project Technical Assistance Center to assist VA providers with implementing those tools and strategies to improve metabolic side-effect monitoring.

Enhancing the Implementation of Evidence-Based Practices in Clinical Settings: MH-QUERI and VA's Office of Mental Health Operations (OMHO) formed a partnership to facilitate the transfer of evidence-based implementation strategies to operational partners in order to enhance their ability to implement evidence-based practices in front-line clinical settings. OMHO enlisted MH-QUERI implementation experts to train and mentor central operations personnel in the use of an evidence-based implementation facilitation strategy that was tested in a QUERI study. To initiate this process, MH-QUERI investigators developed an Implementation Facilitation Training Manual in partnership with OMHO. The "Implementation Facilitation Training Manual: Using External and Internal Facilitation to Improve Care in the Veterans Health Administration," describes this facilitation strategy for implementing new programs or practices, and details internal and external facilitators' activities and specific roles during all phases. Findings from the QUERI-funded evaluation indicate that this strategy supports successful implementation of complex programs and practices at sites that are unable to do so without assistance.

Developing resources for Clinical Managers and Implementation Scientists: An MH-QUERI project engaged a distinguished expert panel of nationally recognized implementation scientists and mental health clinical managers in a rigorous, multistage process to:

• Establish consensus on a common nomenclature for implementation strategy terms, definitions, and categories;
• Develop recommendations to enhance the match between implementation strategies selected to facilitate the use of evidence-based programs and the context of different service settings; and
• Map strategies to three high-priority VA initiatives (implementing prolonged exposure therapy, measurement-based care for depression in primary care, and antipsychotic metabolic monitoring) in sites with varying contextual and evidence factors.

This work advances knowledge of implementation science taxonomy and informs how best to implement national VA clinical priorities.

Polytrauma and Blast-related Injuries (PT/BRI) QUERI

PT/BRI-QUERI promoted the successful rehabilitation, psychological adjustment, and community reintegration of Veterans who have sustained polytrauma and blast-related injuries. A few of their significant impacts include:

Synthesizing Research and Clinical Experience for Providers of Veterans with Polytrauma and Blast-Related Injuries: The scope of PT/BRI-QUERI includes the full range of health problems, healthcare systems, and psychosocial factors represented in this mission. PT/BRI-QUERI, therefore, is not limited to one medical problem. Instead, this QUERI Center focused on the pattern of comorbidities and related functional problems and healthcare needs among the combat-injured. For example, in collaboration with VA's Physical Medicine and Rehabilitation (PM&R) as well as other Offices (e.g., Mental Health Services and Post-deployment Health), PT-BRI QUERI sponsored a face-to-face meeting to synthesize research and clinical experience from caring for Veterans returning from combat operations. Based on recommendations from this meeting, PM&R held a Polytrauma System of Care Conference in 2015, where PT/BRI-QUERI findings were presented.

Evidence-Based, Integrated, Patient-Centered Care for Veterans with TBI/Polytrauma: To inform service delivery and future research, PT/BRI-QUERI created and distributed annual TBI Utilization Reports which summarized the rate of traumatic brain injury (TBI), mental health, and pain comorbidities, VA service use and healthcare costs in OEF/OIF/OND Veterans. PT/BRI investigators found that in any given year, approximately 7% of OEF/OIF/OND Veterans utilizing VA healthcare services received a diagnosis of TBI in a VA clinic. The vast majority of patients with a TBI diagnosis also had a clinician-diagnosed mental health disorder, and half of those Veterans with diagnosed TBI had both post-traumatic stress disorder (PTSD) and pain diagnoses. Moreover, the median annual cost per Veteran diagnosed with TBI was more than three times higher than for those without TBI. These TBI Utilization Reports are posted online with newer reports available soon at www.polytrauma.va.gov.

Spinal Cord Injury (SCI) QUERI

SCI-QUERI worked to promote optimal health, independence, functioning, quality of life, and productivity of Veterans with spinal cord injury and disorder (SCI/D), through the implementation of evidence-based findings. A few of their significant impacts include:

Improving Influenza Vaccination among Veterans with SCI/D: Weak respiratory muscles, impaired cough, and less effective clearance of secretions are common sequelae following SCI/D. Individuals with SCI/D are at high risk of additional complications, hospitalization, and/or death as a result of contracting influenza. The single most effective way to prevent influenza is annual vaccination. SCI-QUERI's efforts have resulted in:

• Influenza vaccination rates increasing from 28% in 2000 to 79% in 2010, and pneumococcal pneumonia vaccination rates increasing from 40% in 2000 to 94% in 2010 in Veterans with SCI/D;
• Developing and disseminating educational materials including a brief video that clarify misconceptions regarding respiratory infections and vaccinations in Veterans with SCI/D and healthcare workers (HCWs) (toolkit and DVD for Veterans with SCI/D and SCI-specific fact booklet for HCWs);
• Facilitating the modification of the VA computerized clinical reminder for vaccination to include all Veterans with SCI/D as high risk regardless of age; and
• The identification of individuals with SCI/D as being a high-risk population by incorporating this into VA and the Centers of Disease Control and Prevention (CDC) vaccination policies and recommendations.

Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in SCI/D: Persons with SCI/D are at high risk of healthcare-associated infections (HAIs) because of system-level impairments (e.g., impaired respiratory function, neurogenic bladder), frequent and prolonged hospitalizations, use of invasive devices, and chronic pressure ulcers. SCI-QUERI collaborated with VA SCI/D Services and the VA Multi-Drug Resistant Organism (MDRO) Program Offices to evaluate VA's National MRSA Prevention Initiative in SCI units. In collaboration with these operations partners, SCI-QUERI examined current practices and identified barriers and facilitators to implementation of the MRSA Prevention Program. QUERI also developed, tested and disseminated an SCI/D MRSA educational toolkit (SCI/D MET) for providers to use to educate Veterans with SCI/D and their informal caregivers about MRSA. The toolkit can be found at http://vaww.sci.va.gov/SCI_MRSA.asp. [Intranet only]

• The toolkit is an educational package that can be used by SCI providers that considers the unique aspects of MRSA prevention and management in individuals living with SCI/D in the community and in the SCI clinical setting.
• Educational material content was derived directly from information patients and their caregivers wanted to know, as well as the information providers felt they needed to know for MRSA prevention and management.

Pressure Ulcer Prevention and Treatment: Pressure ulcers (PrUs) are a serious, costly, and lifelong complication that often follows SCI/D. Because of the critical need for an assessment tool to monitor PrU healing, the SCI Pressure Ulcer Management Tool (SCI-PUMT) was developed with VA funding. Using a collaborative approach, SCI-QUERI worked with SCI/D Services to implement the SCI-PUMT across SCI centers using a collaborative approach. The SCI-PUMT can be found at http://vaww.sci.va.gov/Training.asp. [Intranet only]

• The SCI-PUMT is an evidence-based tool for assessing PrU healing and its use supports implementation of recommended PrU practices.
• Efforts to support use of PUMT as part of clinical practice, including the development of clinical processes to support documentation of and use of PUMT data are ongoing and supported by ongoing efforts with the operations partner.

Stroke-QUERI

Since 2004, Stroke-QUERI has been committed to working across the continuum of care from prevention, to in-hospital care, to rehabilitation to improve the care and outcomes for Veterans at risk and those who have sustained an ischemic stroke. A few of their significant impacts include:

Improving In-Hospital Management of Veterans with Stroke: Stroke-QUERI's work to improve in-hospital management of ischemic stroke targets two main areas:

• Developing systems to document, measure, and improve inpatient stroke care processes and quality; and
• Conducting active implementation projects to foster ongoing inpatient stroke quality improvement activities and improve VA stroke care.

Stroke QUERI made several key impacts in improving in-hospital care. One major area of work was the development and validation of five of the eight inpatient stroke Meaningful Use electronic clinical quality measures (VTE prophylaxis and antithrombotic medication by hospital day two, antithrombotic medication at discharge, consideration for rehabilitation, and anticoagulation for atrial fibrillation), and an electronic VA IPEC stroke quality measure for the assessment of stroke severity with the NIH Stroke Scale.

As a major partner in the development and implementation of the VHA Acute Ischemic Stroke Directive (AIS Directive), Stroke-QUERI investigators used national stroke quality data collected as part of the VHA Stroke Special Study to play a critical role in developing, implementing, and monitoring the national reorganization of VA acute ischemic stroke care. This effort included developing and implementing three IPEC stroke quality measures (tPA for eligible patients, NIHSS performed, dysphagia screening) that are reported monthly by each facility.

In addition, Stroke-QUERI investigators led a project to evaluate facility response to the Directive-stimulated evidence-based reorganization of stroke care. Conducting interviews with 38 VAMC stroke teams, Stroke-QUERI investigators elicited key barriers and facilitators to responding to the Directive. One key finding is that sites that had a "reluctant" clinical champion often struggled to implement and coordinate protocols across all of the clinical services involved in acute stroke care. In addition, VA Stroke Centers identified the importance of electronic tools to help track and monitor care, and the presence of an effective nurse champion to link the different services and people to promote change and measure results.

Finally, Stroke-QUERI investigators conducted a randomized trial of an intervention with external facilitation at 11 VAMCs to improve two inpatient stroke quality indicators. The study showed that SR training accelerated improvement rates during the intervention phase, but that in the year after the intervention the sites receiving only indicator feedback reached similar levels of improvement, suggesting that for prepared sites with a champion that audit and feedback may be adequate to prompt care improvements. An additional SDP conducting longitudinal interviews at these same participating VAMCs assessed the sustainability of implementation effect and identified key organization and team factors related to the quality and sustainability of improvement efforts. This study found that engaging providers and groups in "Reflecting and Evaluating" activities was a key driver of implementation success.

Improving Risk Factor Management for High-risk Patients: Stroke-QUERI's work to improve risk factor management targets two main areas:

• Identifying high risk patients; and
• Identifying gaps in care for Veterans at high risk of stroke.

Within this goal area, Stroke-QUERI investigators developed an administrative data-derived Framingham Stroke Risk score, providing a way to identify Veterans at highest risk of stroke for targeted improvement activities.

Several Stroke-QUERI projects focused on improving self-management of vascular risk factors, including a series of projects demonstrating the efficacy of a telephone-delivered medication management and behavioral program to improve blood pressure control among high-risk Veterans, and a program that demonstrated improvements in self-efficacy and quality of life for Veterans learning to self-manage stroke risk factors through behavior change after stroke or TIA (transient ischemic attack).

Stroke-QUERI investigators also conducted the first national study of TIA care quality, a project which included the development of 25 electronic TIA quality measures. This study demonstrated some areas where Veterans are receiving routinely high levels of TIA care, and some aspects of care with need for improvement, and also demonstrated tremendous variability in the organization of TIA care across multiple specialties and facility service lines.

Contributing toward VA Policy on Stroke Care: Stroke-QUERI has organized policy work in two related areas:

• Evaluating stroke performance metrics for VA that were proposed by Centers for Medicare and Medicaid Services (CMS) for the Medicare program; and
• Developing and evaluating models of stroke care structures, costs, and outcomes to inform VA stroke care organization.

For example, Stroke-QUERI evaluated whether 30-day stroke mortality and readmission models could be useful to compare VAMC facility performance. Investigators found that 30-day stroke mortality has little variability across facilities, and that the inclusion of the NIHSS in the mortality models as a severity measure did not significantly change facility rankings. Thus, the 30-day mortality measure is statistically valid but not useful to identify facilities providing superior or inferior stroke care.

Substance Use Disorder (SUD) QUERI

SUD-QUERI has worked to improve the detection and treatment of Veterans with SUD and hazardous substance use, including developing and evaluating strategies to implement evidence-based treatments, as well as strategies to de-implement ineffective practices. A few of their significant impacts include:

Enhance Treatment for Alcohol Misuse in Primary Care: Many patients with alcohol misuse may benefit from brief alcohol counseling that can be delivered by non-specialists. Successful SUD-QUERI projects include:

• Alcohol screening: Worked with the Office of Analytics and Business Intelligence (OABI) to implement evidence-based alcohol screening using the Alcohol Use Disorders Identification Test Consumption (AUDIT-C).
• Screening and intervention programs for special populations: Evaluation of pre-operative alcohol screening indicated more patients with alcohol misuse are identified by the AUDIT-C than direct assessment of typical drinking, and that the rate of 30-day post-operative complications increases with increasing AUDIT-C scores.
• Brief alcohol counseling: Developed a national clinical reminder and, in collaboration with OABI, a performance measure for brief alcohol counseling, both of which were associated with significant increases in documented brief alcohol counseling. Ongoing initiatives are focused on the quality of brief alcohol counseling.
• Implementation of evidence-based treatment for alcohol use disorders in the primary care setting: Given that the vast majority of alcohol use disorders are identified in the primary care setting and that the majority of patients referred to SUD specialty care do not follow through with their referral, SUD QUERI has focused on developing strategies to implement evidence-based AUD treatment options into the primary care setting and evaluating their effectiveness and feasibility.

Promote Evidence-Based Specialty Care for Patients with SUD: SUD-QUERI continues to promote access, engagement, and retention in high quality SUD specialty care by promoting implementation of evidence-based pharmacotherapies and psychotherapies. This work included providing integrated tobacco treatment. Based on previous work identifying gaps in tobacco treatment, and barriers and facilitators to implementation, SUD-QUERI investigators developed and disseminated a toolkit for implementing tobacco treatment in SUD Residential Treatment Programs in partnership with the Clinical Public Health Group Tobacco and Health: Policy & Programs Division.

Improve Opioid Prescribing Practices: A series of SUD-QUERI projects on opioid prescribing practices has produced system-wide impacts, most notably the development of the Opioid Therapy Guideline Adherence Report – a suite of national metrics to assess gaps in guideline-recommended opioid therapy practices.

Identify strategies to improve Opioid Overdose Education and Naloxone Distribution (OEND): OEND involves training individuals to prevent, recognize, and respond to an opioid overdose, including responding with naloxone, a medication used to reverse opioid overdose. As of 2015, more than 650 naloxone rescue kits have been distributed and the kits have already been used to reverse 11 reported opioid overdoses. SUD-QUERI also interviewed early adopters of OEND implementation within VA to identify strategies to enhance future OEND implementation.