Using QUERI & Using QUERI & Implementation Science Implementation Science

Theories and Theories and Frameworks to Improve Frameworks to Improve

Access and EquityAccess and EquityS. Randal Henry, DPH, MPH

QUERI HIV/Hepatitis C

PrefacePreface

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Overview Overview

1. Does implementation of disparities reduction programs differ from general quality improvement interventions?

2. How can implementation science contribute to disparities reduction research?

3. How can collaboration and partnership-building contribute to the reduction of health disparities?

4. How can we develop and implement programs that address the need for comprehensive, integrated care for patients with multiple co-morbid conditions that require care across multiple services lines?

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The VA Healthcare System: The VA Healthcare System: An Ideal Environment for Disparities An Ideal Environment for Disparities

ResearchResearch Patients are racially and ethnically diverse and

many are economically disadvantaged Access to healthcare is similar across veteran

populations, eliminating this key reason for disparities in health care

Computerized clinical and administrative national databases on veterans served

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VA HSR&D and Disparities VA HSR&D and Disparities ResearchResearch

The VA supports disparities research Improving access to care and reducing health

disparities is a priority research focus Established the Center for Health Equity Research

and Promotion (CHERP) and Center for Disease Prevention and Health Interventions for Diverse Populations

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Poll QuestionPoll Question

Does the implementation of access and equity improvement interventions differ from general quality improvement (QI) interventions?

Yes No

Cyber Seminar Cyber Seminar GoalsGoals

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CyberSeminar GoalsCyberSeminar Goals

Encourage the quality improvement community to address impaired access and inequitable distribution of care

Encourage the access and equity community to utilize implementation research

Promote the use of implementation science to reduce health disparities 

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Introduction:Introduction:

The VA is committed to delivering high quality

healthcare care in an equitable manner.

What are Health What are Health Disparities?Disparities?

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Health disparities are Health disparities are differences…differences…

in the quantity and quality of healthcare provision

in the prevalence, mortality, and burden of disease and other adverse health conditions

not due to access related factors, clinical need, preferences, or appropriateness of the intervention (IOM)

Poll QuestionPoll Question

In the course of your research or clinical practice, have you identified a health disparity?

Yes?

No?

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Evidence of disparitiesEvidence of disparities

Evidence of racial and ethnic disparities in health care is consistent across a range of illnesses and healthcare services. (Smedley et

al)

Disparities have been demonstrated in the Veterans Affairs (VA) healthcare system.

Smedley B, Stith A, & Nelson AR.Unequal treatment confronting racial and ethnic disparities in healthcare. City: National Academies Press (US), 2003.

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Inequities within the VAInequities within the VA Associated with

age, gender, race/ethnicity and income:

More consistently observed for processes that:

entail more risk and require more intensive decision making & communication

require more effort on the part of patients and/or providers

medication adherence

Associated with geographic location: When compared to their urban

counterparts, rural veterans have; worse health-related quality-of-

life report less access to care use fewer healthcare services are more dependent on the VA

for their healthcare services travel burden to specialty

services is substantially greater research on rural veterans health

and health care is lacking.

Saha S, Freeman M, Toure J, et al. Racial and ethnic disparities in the VA healthcare system: a systematic review. 2007 Jun. Department of Veterans Affairs HSR&D

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Vulnerable Patient Vulnerable Patient GroupsGroups

Racial/ethnic minorities Women Homeless Elderly Low socioeconomic status Stigmatizing medical or psychiatric illness Diminished autonomy

Disparities by Disparities by QUERI QUERI

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Disparities By Clinical Disparities By Clinical Content AreaContent Area

Disparities

Clinical Content Area QUERI Group Present Not Present

Arthritis/pain management 6 1

Cancer treatment 2 2

Diabetes Diabetes Mellitus 7 2

Heart and vascular disease Chronic Heart Failure and Ischemic Heart

Disease

20 10

HIV/Hepatitis C HIV/Hepatitis 4 3

Mental health/substanceabuse

Mental Health and Substance Use

Disorders

11 10

Preventive/ambulatory care 8 4

Rehabilitation and palliativecare

Polytrauma and Blast Related Injuries

2 2

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Utilization or Outcome Measure DisparitiesPresent

DisparitiesNot Present

Surgery and invasive procedures 21 11

Medication Use Prescribing Adherence

95

70

Basic services/processes of care* 13 10

Referral 1 2

Patient satisfaction 2 3

Intermediate outcomes** 5 1

Saha S, Freeman M, Toure J, Tippens K, Weeks C. HSR&D Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review (2007)

*E.g.: lab tests, outpatient visits

**E.g.: control of blood pressure, blood glucose, lipids

Disparities By Disparities By Utilization/Outcome Utilization/Outcome

MeasureMeasure

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Polling Questions #2Polling Questions #2

What is the key barrier to improving access and equity for veterans?

1. Individual/patient-level factors

2. Organizational/institutional factors

Which VA Programs Which VA Programs Address Access and Address Access and

Equity?Equity?

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The VA may be able to address individual and institutional barriers to care

A greater understanding of the prevalence and influence of these processes is needed and should be sought through research

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Center for Health Equity Center for Health Equity Research and Promotion Research and Promotion

(CHERP)(CHERP) HSR&D Center of Excellence

Promote equity and quality in health and health care

A collaboration among key entities within VISN4  Investigators played key roles in the development

of Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review

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VA Center for Minority VA Center for Minority VeteransVeterans

Goals Provide and promote the use of VA

programs, benefits, and services use by minority veterans

Make benefits and services more accessible to minority veterans

Evaluate current programs and make recommendations on how VA can better serve minority veterans

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Office of Quality and Office of Quality and Performance (OQP)Performance (OQP)

Operational focus on disparities Race/ethnicity Gender

OQP custodian of rich source of data for health disparities research OQP Chronic pain (race) Alcohol Counseling (race) Immunization (gender) Quality of Care (mental health, MS, SCI, Chronic illness,

rural/urban)

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Poll QuestionPoll Question

What do you think is the major barrier to addressing disparities? Documenting/diagnosing/identifying

organizational factors that contribute to disparities Designing/delivering disparities reduction

programs Creating policy changes Overcoming organizational barriers

What is Implementation Science?

How can it help reduce identified health disparities?

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Implementation Science Implementation Science (IS)(IS)

Implementation Science is the study of the systematic uptake of knowledge and the implementation of that knowledge into routine organizational practice (and everything that facilitates or impedes it)

Typically conducted in health services settings Includes examination of the influence of contextual factors

(e.g. organizational policy) and individual factors (e.g. healthcare professionals) on organizational behavior

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Implementation Science Implementation Science can…can…

Develop standards for evaluating access and equity

Generate new insights and generalizable knowledge regarding dissemination / implementation of disparities reduction

Develop, test and refine disparities reduction theories, hypotheses, models and principles

Determine the relative effect of quality improvement interventions among patients at highest risk for impaired access and inequitable care

Four Implementation Science Frameworks that can be used to

Assess Access and Equity

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CHERP Conceptual CHERP Conceptual Model for Health Model for Health

Disparities ResearchDisparities ResearchFirst Generation Detect disparities in

health or health care

Second Generation

Third Generation

Understand reasons for disparities

Develop interventions to eliminate disparities

Kilbourne et al. American Journal of Public Health, December 2006

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Behavioral Model of Behavioral Model of VulnerabilityVulnerability

Chart Adapted from: Gelberg, L, Andersen RM, and Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people (2000)

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SuccessfulImplementation

= f (E, C, F)

Evidence= Research; Clinical experience;

Patient experience; & Local knowledge

Context= Receptive context; Culture;

Leadership; & Evaluation

Facilitation= Purpose; Role; Skill & Attributes

PARIHS FrameworkPARIHS Framework

PRECEDE PROCEED PRECEDE PROCEED FrameworkFramework

Phase 5 Administration and Policy Diagnosis

Phase 4 Educational and Organizational Diagnosis

Phase 3 Behavioral and Environmental Diagnosis

Phase 2 Epidemiological Diagnosis

Phase 1 Social Diagnosis

Health Promotio

n

Phase 6 Implementation

Phase 7 Process Evaluation

Phase 8 Impact Evaluation

Phase 9 Outcome Evaluation

Health education

Policy regulation organization

Predisposing factors

Reinforcing factors

Enabling factors

Behavior and Lifestyle

Environment

HealthQuality of Life

PRECEDEPRECEDE

PROCEEDPROCEED

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Polling Questions # 3Polling Questions # 3

What is the key barrier to Quality Improvement (QI) in medical care delivery?

1. Individual factors

2. Societal Factors

3. VA related organizational/institutional factors

IV. Utilizing the QUERI IV. Utilizing the QUERI Model to Improve Model to Improve Access and EquityAccess and Equity

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QUERI MissionQUERI Mission

Enhance the quality and outcomes of VA health care by systematically implementing clinical research findings and evidence-based recommendations into routine clinical practice. practice needs determine the research agenda research results determine interventions that

improve the quality of patient care.

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QUERI Four-Phase QUERI Four-Phase Implementation Research Implementation Research

FrameworkFramework

Phase Study Type Form of Evaluation

Pre-trial Program Conceptual design of implementation program and underlying design (logic) model from theory, prior empirical research

Phase 1 Pilot / Pilot test, assess feasibility, formative evaluation and refinement,Formative develop intervention/evaluation protocols

Phase 2 Efficacy Small-scale rigorous trial in controlled settings with ongoingintervention support; emphasis on internal validity

Phase 3 Effectiveness Large-scale rigorous trial under routine conditions in variedsettings; emphasis on external validity

Phase 4 Monitoring Ongoing monitoring and feedback

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The The ClassicClassic Six-Step Six-Step QUERI ProcessQUERI Process

1. Identify high risk/high burden conditions

2. Identify best practices

3. Define existing practice patterns in VA and variations from best practices

4. Identify (or develop) and implement programs to promote best practices

5. Document outcome and system improvements

6. Document improvements in health-related quality of life

V. Next StepsV. Next Steps

Using Implementation Science to Study and Promote Equity

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Future Directions for VA Future Directions for VA Disparities ResearchDisparities Research

Leading investigations to better understand the patient, provider, and system level causes of health disparities

Developing and evaluating new interventions to reduce health disparities

Improve the quality and equity of VA health care through effective collaborations and dissemination of research findings

Ensuring that health care equity is considered an integral component of health care quality in VA

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PollPoll

What is the best method to improve the overall health status of all veterans? Develop specific programs for the most vulnerable

(high-risk) patient groups Develop universal interventions (designed to

improve the health of all)

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SummarySummary

The VA is an ideal setting to conduct first, second, and third generation disparities research

The VA HSR&D is committed to supporting this line of investigation and to training the next generation of disparities researchers

The VA is a national leader in advancing the field of disparities research, generating findings highly relevant to other health care systems

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VA HSR&D

CHERP

VA CIPRS

VA QUERI (esp. HIV/Hepatitis C)

OQP

Acknowledgements Acknowledgements