Comparative Effectivenss

7/29/2019 Comparative Effectivenss

1/19

Implementing the

Findings of

Comparative

Effectiveness Research

David Atkins MD, MPHDirector, QUERI Program


2/19

What Ill Say

Many of the challenges of translation of researchinto practice are similar inside VA and outside

o Difficulty of changing provider behavior, movingcomplex organizations

What we have learned is very relevant to othersystems

Certain unique aspects of VA organizationHAVE made it easier for us to achieve change

o HIT, integration of care, alignment of incentives

Many of these features CAN and ARE beingadopted by outside organizations to improve

success


3/19

Closing the Quality Gap

Uneven delivery of effective care well-documented

Only 50% of effective interventions arereliably delivered

If we only focus on GENERATING more

information on comparative effectiveness,without attending to how to IMPLEMENTit, we will not improve quality or value orprovide return on CER investment.


4/19

Copyright restrictions may apply.

Dougherty, D. et al. JAMA 2008;299:2319-2321.

The 3 Translational Blocks


5/19

CER andImplementation

How can implementation research help us

get the most reward from investment inCER?

o Is implementing CER different than

implementing any new evidence?

How can we apply CER to identify the

most effective implementation strategies?


6/19

Building a CoordinatedImplementation

Strategy in VA - QUERI Established in VA in 1998 as part of

sweeping reforms in VHA

Designed to speed the uptake and spreadof evidence-based care throughout the VA

Based on principles ofimplementation

science Understanding and overcoming barriers to

adoption of new practices


7/19

QUERI Coordinating Centers

Substance Abuse

Houston, TX

CHF-QUERI

Palo Alto, CA

HIV/HEPATITIS C-QUERIGreater Los Angeles

Polytrauma/Blast Injury

Minneapolis, MN

Ischemic Heart Disease

Seattle, WA

Diabetes

Ann Arbor, MI

Mental HealthLittle Rock, AR

Spinal Cord Injury

Hines, IL

QUERI Centers

STROKE-QUERI

Indianapolis, IN


8/19

QUERIs Research/Implementation

Pipeline

ImplementationResearch

Implement Intervention &Document outcome

Clinical Research /Guideline

Development

Mainstream HealthServices Research

Assess Existing Practice

IdentifyResearch

AreaIdentify Best

Practice

Implementation

Policy, ImprovedHealth

Phase 1Pilot Projects

Phase 2Small-Scale

Demonstrations

Phase 3Regional

Demonstrations

Phase 4NationalRollout


9/19

Why Dont Clinicians andPatients Select the Best

Treatments Knowledge gaps dont know latest

evidence

Skills gaps not trained to deliver newinterventions

System barriers organization, leadership,

support, time, resources Technology barriers lack right information


10/19

Evidence SynthesisProgram

4 centers (including a coordinating Center)

Take advantage of capacity of AHRQ

Evidenced-based Practice Centers

Quick turn-around reviews of Veteran-

specific topics (e.g. suicide prevention,

disparities in VA) Apply Veteran-specific lens to research

synthesis

Inform VA policies


11/19

Tools Used By VA toFacilitate Implementation

Provider Educationo CME, Clinical Practice Guidelines

Patient Education:o MyHealtheVet, self-management support, care

managers

HIT: Electronic Health Recordo Electronic Reminders

o Computerized Decision Support

National Formulary Policies

Performance Measures and Reporting

Incentives


12/19

Example: ImplementingCollaborative Care to

Improve Depression Rx

Multiple studies demonstrate advantage of

collaborative care for depression

Mental Health QUERI Program -- TIDES

o Demonstrate success at a few facilities

o Show it can be rolled out broadly

o Test its transferability to different settings

(e.g. substance abuse clinics)


13/19

What is Needed forSpread and Adoption

Tools:o Care manager training manual

o Redesign tools for local champions, Fidelity tools

Trainingo In-person training (continuing education services)

o Train the Trainer

ITo Care management assessment and follow-up

o Consultation software TIDES scripts

o Case load management software Fo

o Formalized training curriculum


14/19

Implementation of System ChangeCollaborative Care of Depression

Depression

CollaborativeCare Model

Black Hills

Twin Ports

Sioux Falls

Beaumont

Pensacola

Lufkin

Akron

CantonYoungstown

Depression symptoms

Depression severity

Anti-depressant meds

Barriers to collaboration

Collaborative care costs

Implementation fidelity

Outpatient utilization

Patient satisfactionHospitalization ratesVISN 10

Sustainability in

1st-generation sites1st-generation sites

2nd-generation

site

s

BRIDGE

to

NationalRollout

Single 3 VISNs 18-30 sites Nationalsite 9 sites 4 VISNs Rollout

C ti Eff ti


15/19

Comparative EffectivenessResearch of

Implementation Many options for facilitating adoption of

CER

Tradeoffs of costs, effectiveness,feasibility

o E.g. Reminder fatigue

We need to compare different approachesto find most efficient combinations

Example: What is relative yield of audit

and feedback, national performance


16/19

What Have We LearnedFrom Implementation

Science? Multiple models to explain change process Common factors:

o Importance and priority of change (leadershipcommitment)

o Local context and capability

o Nature of change

Most changes require active facilitationo Local champions, tools, training

Barriers differ with specific context

o Leadership, resources, IT, inertia


17/19


18/19

Lessons from VA andQUERI

No single or simple solution for

implementation

o Contextis critical: intervention, setting, patiento Education may be necessary but never

sufficient

HIT tools can be an important component ofimplementation

Effective implementation may require

redesigning the care process

-


19/19

Bridging theTranslation Gap

Documents

Comparative Effectivenss