Dataset Information

Implementing electronic clinical reminders for lipid management in patients with ischemic heart disease in the veterans health administration: QUERI Series.

ABSTRACT:

Background

Ischemic heart disease (IHD) affects at least 150,000 veterans annually in the United States. Lowering serum cholesterol has been shown to reduce coronary events, cardiac death, and total mortality among high risk patients. Electronic clinical reminders available at the point of care delivery have been developed to improve lipid measurement and management in the Veterans Health Administration (VHA). Our objective was to report on a hospital-level intervention to implement and encourage use of the electronic clinical reminders.

Methods

The implementation used a quasi-experimental design with a comparison group of hospitals. In the intervention hospitals (N = 3), we used a multi-faceted intervention to encourage use of the electronic clinical reminders. We evaluated the degree of reminder use and how patient-level outcomes varied at the intervention and comparison sites (N = 3), with and without adjusting for self-reported reminder use.

Results

The national electronic clinical reminders were implemented in all of the intervention sites during the intervention period. A total of 5,438 patients with prior diagnosis of ischemic heart disease received care in the six hospitals (3 intervention and 3 comparison) throughout the 12-month intervention. The process evaluation showed variation in use of reminders at each site. Without controlling for provider self-report of use of the reminders, there appeared to be a significant improvement in lipid measurement in the intervention sites (OR 1.96, 95% CI 1.34, 2.88). Controlling for use of reminders, the amount of improvement in lipid measurement in the intervention sites was even greater (OR 2.35, CI 1.96, 2.81). Adjusting for reminder use demonstrated that only one of the intervention hospitals had a significant effect of the intervention. There was no significant change in management of hyperlipidemia associated with the intervention.

Conclusion

There may be some benefit to focused effort to implement electronic clinical reminders, although reminders designed to improve relatively simple tasks, such as ordering tests, may be more beneficial than reminders designed to improve more complex tasks, such as initiating or titrating medications, because of the less complex nature of the task. There is value in monitoring the process, as well as outcome, of an implementation effort.

SUBMITTER: Sales A

PROVIDER: S-EPMC2423370 | biostudies-literature | 2008 May

REPOSITORIES: biostudies-literature

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Publications

Implementing electronic clinical reminders for lipid management in patients with ischemic heart disease in the veterans health administration: QUERI Series.

Sales Anne A Helfrich Christian C Ho P Michael PM Hedeen Ashley A Plomondon Mary E ME Li Yu-Fang YF Connors Alison A Rumsfeld John S JS

Implementation science : IS 20080529

<h4>Background</h4>Ischemic heart disease (IHD) affects at least 150,000 veterans annually in the United States. Lowering serum cholesterol has been shown to reduce coronary events, cardiac death, and total mortality among high risk patients. Electronic clinical reminders available at the point of care delivery have been developed to improve lipid measurement and management in the Veterans Health Administration (VHA). Our objective was to report on a hospital-level intervention to implement and ...[more]

PMID: 18510748

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Project description:BackgroundHuman Subjects protections approaches, specifically those relating to research review board oversight, vary throughout the world. While all are designed to protect participants involved in research, the structure and specifics of these institutional review boards (IRBs) can and do differ. This variation affects all types of research, particularly implementation research.MethodsIn 2001, we began a series of inter-related studies on implementing evidence-based collaborative care for depression in Veterans Health Administration primary care. We have submitted more than 100 IRB applications, amendments, and renewals, and in doing so, we have interacted with 13 VA and University IRBs across the United States (U.S.). We present four overarching IRB-related themes encountered throughout the implementation of our projects, and within each theme, identify key challenges and suggest approaches that have proved useful. Where applicable, we showcase process aids developed to assist in resolving a particular IRB challenge.ResultsThere are issues unique to implementation research, as this type of research may not fit within the traditional Human Subjects paradigm used to assess clinical trials. Risks in implementation research are generally related to breaches of confidentiality, rather than health risks associated with traditional clinical trials. The implementation-specific challenges discussed are: external validity considerations, Plan-Do-Study-Act cycles, risk-benefit issues, the multiple roles of researchers and subjects, and system-level unit of analysis.DiscussionSpecific aspects of implementation research interact with variations in knowledge, procedures, and regulatory interpretations across IRBs to affect the implementation and study of best methods to increase evidence-based practice. Through lack of unambiguous guidelines and local liability concerns, IRBs are often at risk of applying both variable and inappropriate or unnecessary standards to implementation research that are not consistent with the spirit of the Belmont Report (a summary of basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research), and which impede the conduct of evidence-based quality improvement research. While there are promising developments in the IRB community, it is incumbent upon implementation researchers to interact with IRBs in a manner that assists appropriate risk-benefit determinations and helps prevent the process from having a negative impact on efforts to reduce the lag in implementing best practices.

Project description:Importance:The Department of Veterans Affairs (VA) operates a nationwide system of hospitals and hospital-affiliated clinics, providing health care to more than 2 million veterans with cardiovascular disease. While data permitting hospital comparisons of the outcomes of acute cardiovascular care (eg, myocardial infarction) are publicly available, little is known about variation across VA medical centers (VAMCs) in outcomes of care for populations of patients with chronic, high-risk cardiovascular conditions. Objective:To determine whether there are substantial differences in cardiovascular outcomes across VAMCs. Design, Setting, and Participants:Retrospective cohort study comprising 138 VA hospitals and each hospital's affiliated outpatient clinics. Patients were identified who received VA inpatient or outpatient care between 2010 and 2014. Separate cohorts were constructed for patients diagnosed as having either ischemic heart disease (IHD) or chronic heart failure (CHF). The data were analyzed between June 24, 2015, and November 21, 2017. Exposures:Hierarchical linear models with VAMC-level random effects were estimated to compare risk-standardized mortality rates for IHD and for CHF across 138 VAMCs. Mortality estimates were risk standardized using a wide array of patient-level covariates derived from both VA and Medicare health care encounters. Main Outcomes and Measures:All-cause mortality. Results:The cohorts comprised 930 079 veterans with IHD and 348 015 veterans with CHF; both cohorts had a mean age of 77 years and were predominantly white (IHD, n = 822 665 [89%] and CHF, n = 287 871 [83%]) and male (IHD, n = 916 684 [99%] and CHF n = 341 352 [98%]). The VA-wide crude annual mortality rate was 7.4% for IHD and 14.5% for CHF. For IHD, VAMCs' risk-standardized mortality varied from 5.5% (95% CI, 5.2%-5.7%) to 9.4% (95% CI, 9.0%-9.9%) (P < .001 for the difference). For CHF, VAMCs' risk-standardized mortality varied from 11.1% (95% CI, 10.3%-12.1%) to 18.9% (95% CI, 18.3%-19.5%) (P < .001 for the difference). Twenty-nine VAMCs had IHD mortality rates that significantly exceeded the national mean, while 35 VAMCs had CHF mortality rates that significantly exceeded the national mean. Veterans Affairs medical centers' mortality rates among their IHD and CHF populations were not associated with 30-day mortality rates for myocardial infarction (R2 = 0.01; P = .35) and weakly associated with hospitalized heart failure 30-day mortality (R2 = 0.16; P < .001) and the VA's star rating system (R2 = 0.06; P = .005). Conclusions and Relevance:Risk-standardized mortality rates for IHD and CHF varied widely across the VA health system, and this variation was not well explained by differences in demographics or comorbidities. This variation may signal substantial differences in the quality of cardiovascular care between VAMCs.

Project description:BACKGROUND: Continuing challenges to timely adoption of evidence-based clinical practices in healthcare have generated intense interest in the development and application of new implementation methods and frameworks. These challenges led the United States (U.S.) Department of Veterans Affairs (VA) to create the Quality Enhancement Research Initiative (QUERI) in the late 1990s. QUERI's purpose was to harness VA's health services research expertise and resources in an ongoing system-wide effort to improve the performance of the VA healthcare system and, thus, quality of care for veterans. QUERI in turn created a systematic means of involving VA researchers both in enhancing VA healthcare quality, by implementing evidence-based practices, and in contributing to the continuing development of implementation science. The efforts of VA researchers to improve healthcare delivery practices through QUERI and related initiatives are documented in a growing body of literature. The scientific frameworks and methodological approaches developed and employed by QUERI are less well described. A QUERI Series of articles in Implementation Science will illustrate many of these QUERI tools. This Overview article introduces both QUERI and the Series. METHODS: The Overview briefly explains the purpose and context of the QUERI Program. It then describes the following: the key operational structure of QUERI Centers, guiding frameworks designed to enhance implementation and related research, QUERI's progress and promise to date, and the Series' general content. QUERI's frameworks include a core set of steps for diagnosing and closing quality gaps and, simultaneously, advancing implementation science. Throughout the paper, the envisioned involvement and activities of VA researchers within QUERI Centers also are highlighted. The Series is then described, illustrating the use of QUERI frameworks and other tools designed to respond to implementation challenges. CONCLUSION: QUERI's simultaneous pursuit of improvement and research goals within a large healthcare system may be unique. However, descriptions of this still-evolving effort, including its conceptual frameworks, methodological approaches, and enabling processes, should have applicability to implementation researchers in a range of health care settings. Thus, the Series is offered as a resource for other implementation research programs and researchers pursuing common goals in improving care and developing the field of implementation science.

Project description:BackgroundNo-shows are a persistent and costly problem in all healthcare systems. Because forgetting is a common cause of no-shows, appointment reminders are widely used. However, qualitative research examining appointment reminders and how to improve them is lacking.ObjectiveTo understand how patients experience appointment reminders as part of intervention development for a pragmatic trial of enhanced appointment reminders.DesignQualitative content analysis PARTICIPANTS: Twenty-seven patients at a single Department of Veterans Affairs hospital and its satellite clinics APPROACH: We conducted five waves of interviews using rapid qualitative analysis, in each wave continuing to ask veterans about their experience of reminders. We double-coded all interviews, used deductive and inductive content analysis to identify themes, and selected quotations that exemplified three themes (limitations, strategies, recommendations).Key resultsInterviews showed four limitations on the usability of current appointment reminders which may contribute to no-shows: (1) excessive information within reminders; (2) frustrating telephone systems when calling in response to an appointment reminder; (3) missing or cryptic information about clinic logistics; and (4) reminder fatigue. Patients who were successful at keeping appointments often used specific strategies to optimize the usability of reminders, including (1) using a calendar; (2) heightening visibility; (3) piggybacking; and (4) combining strategies. Our recommendations to enhance reminders are as follows: (1) mix up their content and format; (2) keep them short and simple; (3) add a personal touch; (4) include specifics on clinic location and contact information; (5) time reminders based on the mode of delivery; and (6) hand over control of reminders to patients.ConclusionsAppointment reminders are vital to prevent no-shows, but their usability is not optimized for patients. There is potential for healthcare systems to modify several aspects of the content, timing, and delivery of appointment reminders to be more effective and patient-centered.

Project description:BackgroundLittle is known about effective strategies for disseminating and implementing complex clinical innovations across large healthcare systems. This paper describes processes undertaken and tools developed by the U.S. Department of Veterans Affairs (VA) Mental Health Quality Enhancement Research Initiative (MH-QUERI) to guide its efforts to partner with clinical leaders to prepare for national dissemination and implementation of collaborative care for depression.MethodsAn evidence-based quality improvement (EBQI) process was used to develop an initial set of goals to prepare the VA for national dissemination and implementation of collaborative care. The resulting product of the EBQI process is referred to herein as a "National Dissemination Plan" (NDP). EBQI participants included: a) researchers with expertise on the collaborative care model for depression, clinical quality improvement, and implementation science, and b) VA clinical and administrative leaders with experience and expertise on how to adapt research evidence to organizational needs, resources and capacity. Based on EBQI participant feedback, drafts of the NDP were revised and refined over multiple iterations before a final version was approved by MH-QUERI leadership. 'Action Teams' were created to address each goal. A formative evaluation framework and related tools were developed to document processes, monitor progress, and identify and act upon barriers and facilitators in addressing NDP goals.ResultsThe National Dissemination Plan suggests that effectively disseminating collaborative care for depression in the VA will likely require attention to: Guidelines and Quality Indicators (4 goals), Training in Clinical Processes and Evidence-based Quality Improvement (6 goals), Marketing (7 goals), and Informatics Support (1 goal). Action Teams are using the NDP as a blueprint for developing infrastructure to support system-wide adoption and sustained implementation of collaborative care for depression. To date, accomplishments include but are not limited to: conduct of a systematic review of the literature to update VA depression treatment guidelines to include the latest evidence on collaborative care for depression; training for clinical staff on TIDES (Translating Initiatives for Depression into Effective Solutions project) care; spread of TIDES care to new VA facilities; and integration of TIDES depression assessment tools into a planned update of software used in delivery of VA mental health services. Thus far, common barriers encountered by Action Teams in addressing NDP goals include: a) limited time to address goals due to competing tasks/priorities, b) frequent turnover of key organizational leaders/stakeholders, c) limited skills and training among team members for addressing NDP goals, and d) difficulty coordinating activities across Action Teams on related goals.ConclusionMH-QUERI has partnered with VA organizational leaders to develop a focused yet flexible plan to address key factors to prepare for national dissemination and implementation of collaborative care for depression. Early indications suggest that the plan is laying an important foundation that will enhance the likelihood of successful implementation and spread across the VA healthcare system.

Project description:BackgroundPrevious research has found that social risk factors are associated with an increased risk of 30-day readmission. We aimed to assess the association of 5 social risk factors (living alone, lack of social support, marginal housing, substance abuse, and low income) with 30-day Heart Failure (HF) hospital readmissions within the Veterans Health Affairs (VA) and the impact of their inclusion on hospital readmission model performance.MethodsWe performed a retrospective cohort study using chart review and VA and Centers for Medicare and Medicaid Services (CMS) administrative data from a random sample of 1,500 elderly (≥ 65 years) Veterans hospitalized for HF in 2012. Using logistic regression, we examined whether any of the social risk factors were associated with 30-day readmission after adjusting for age alone and clinical variables used by CMS in its 30-day risk stratified readmission model. The impact of these five social risk factors on readmission model performance was assessed by comparing c-statistics, likelihood ratio tests, and the Hosmer-Lemeshow goodness-of-fit statistic.ResultsThe prevalence varied among the 5 risk factors; low income (47 % vs. 47 %), lives alone (18 % vs. 19 %), substance abuse (14 % vs. 16 %), lacks social support (2 % vs. <1 %), and marginal housing (< 1 % vs. 3 %) among readmitted and non-readmitted patients, respectively. Controlling for clinical factors contained in CMS readmission models, a lack of social support was found to be associated with an increased risk of 30-day readmission (OR 4.8, 95 %CI 1.35-17.88), while marginal housing was noted to decrease readmission risk (OR 0.21, 95 %CI 0.03-0.87). Living alone (OR: 0.9, 95 %CI 0.64-1.26), substance abuse (OR 0.91, 95 %CI 0.67-1.22), and having low income (OR 1.01, 95 %CI 0.77-1.31) had no association with HF readmissions. Adding the five social risk factors to a CMS-based model (age and comorbid conditions; c-statistic 0.62) did not improve model performance (c-statistic: 0.62).ConclusionsWhile a lack of social support was associated with 30-day readmission in the VA, its prevalence was low. Moreover, the inclusion of some social risk factors did not improve readmission model performance. In an integrated healthcare system like the VA, social risk factors may have a limited effect on 30-day readmission outcomes.

Dataset Information

Implementing electronic clinical reminders for lipid management in patients with ischemic heart disease in the veterans health administration: QUERI Series.

Background

Methods

Results

Conclusion

Publications

Implementing electronic clinical reminders for lipid management in patients with ischemic heart disease in the veterans health administration: QUERI Series.

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