IHD-QUERI Update 2011Research and Methodology Committee

Review Meeting -- January 26, 2011

Stephan D. Fihn, MD, MPHJohn Rumsfeld, MD, PhDChristian Helfrich, PhDMichael Ho, MD, PhD

Blake Wood, MS

Brief overview – IHD in VA IHD QUERI Update

• Productivity• Innovative projects• Extensive network of partners

Implementation Framework ≈ Strategic Plan (CART-CL=prototype)• Focus on systems of care

Ischemic Heart Disease

Acute IHD Care

Chronic IHD Care

Setting of care CCU, ED, Cath lab Clinic – primary care, cardiology

Providers Cardiologists Primary care, cardiologists

Guidelines STEMI; NSTEMI/UA Chronic IHD, Risk Reduction

Approach High tech, invasive “Low” tech, behavioral

Population 11,000 AMI annually ~0.9-1.2 million

State of IHD Care in the VA

VA IHD Care Compared to non-VA

AHA Annual Statistical Update 2011

IHD-QUERI Accomplishments:Past 3 years

• 22 IHD QuERI-affiliated investigators• Funding

20 studies led by IHDQ-affiliated investigators during past 3 years with $7.5 million in funding, including 8 QuERI RRPs

Plus: CART development ($5.3 m) QIR ($240k) Patient-aligned Care Team national evaluation center ($990k)

• 77 publications (2008-2010)

Highlights of Recent IHD-QUERI Accomplishments

Examples• Cardiac Care Follow-up

Clinical Study (CCFCS)• Cardiovascular

Assessment Reporting and Tracking System (CART)

7

8

Actions Taken• New Chief Cardiology Consultant (Dr. Jesse)• National steering committee (including PCS,

operations, research, OQP)• VISN action plans• New performance measures• National training• Technical assistance projects• Major investment in new equipment• Updated clinical guidelines (with AHA/ACC)• National cath lab software package (CART-CL)

CCFCS: AMI mortality within VHA is comparable to Medicare-funded hospitals

Fihn SD, et al. BMC Cardiovascular Disease 2009

CCFCS: Potential for interaction between antiplatelet medication and PPIs

Ho PM, et al. JAMA 2009

Cardiovascular Assessment Reporting and Tracking System for Cath Labs (CART)

Missions of CART1. Clinical care2. Quality improvement3. Research

Current Status of CART(2004-2011; N=77)

CART: Innovative Program for Post-Market Device Surveillance

2007: 1 UED Reported from VA to FDA

???

15 LEVEL III Potentially Device-Related

Patient Complications(FDA reportable MedWatch 3500A)

15 LEVEL III Potentially Device-Related

Patient Complications(FDA reportable MedWatch 3500A)

CART-FDA Device SurveillanceAugust 15, 2006-September 31, 2009

26,554 PCI REPORTSEntered in CART

August 15, 2006-September 31, 200926,554 PCI REPORTS

Entered in CART

308 DEVICE-RELATEDEvents Reported in CART

from 47 sites

308 DEVICE-RELATEDEvents Reported in CART

from 47 sites

215 LEVEL INot Specific to the Medical Device

(deidentified – no PHI)

215 LEVEL INot Specific to the Medical Device

(deidentified – no PHI)

78 LEVEL IIPotentially Device-Related

( details for novel events – no PHI)

78 LEVEL IIPotentially Device-Related

( details for novel events – no PHI)

CART Active Sites and Adoption

Median Rates for Implementation Phases

1 ± 1.8months

3 ± 4.2months

1 ± 2.5months

1 ± 7.6months

CART IMPLEMENTATION: Key Barriers

Contentment with Current Processes

Staff Resource Concerns

Lack of Interfacing with External Systems

CART IMPLEMENTATION: Key Facilitators

EVIDENCE BASED

PRACTICE

IMPLEMENT IMPROVEMENT

PROGRAMS

EVALUATE IMPROVEMENT

PROGRAMS

MEASURE GAPS

DEVELOP MEASURES AND DATA RESOURCES

DEVELOP CLINICAL EVIDENCE

QuERI Steps

EVIDENCE BASED

PRACTICE

IMPLEMENT IMPROVEMENT

PROGRAMS

EVALUATE IMPROVEMENT

PROGRAMS

MEASURE GAPS

DEVELOP MEASURES AND DATA RESOURCES

DEVELOP CLINICAL EVIDENCE

Implementation Practice

Data systems

Operational partnerships

Evolving systems of care

EVIDENCE BASED

PRACTICE

IMPLEMENT IMPROVEMENT

PROGRAMS

EVALUATE IMPROVEMENT

PROGRAMS

MEASURE GAPS

DEVELOP MEASURES AND DATA RESOURCES

DEVELOP CLINICAL EVIDENCE

Implementation Practice

Data systems

Operational partnerships

Evolving systems of care

Studying interventions built

into systems of care

Understanding the influence of organizational context

Robust IHD-QUERI Partnerships

Ischemic Heart Disease

Acute IHD Care

Chronic IHD Care

Leveraging CCFCS and CART to identify gaps in care

Gaps in longitudinal

care

RF management

Patient adherence

Failure to optimize systems of care

Suboptimal coordination/transitions

Gaps in quality metrics

IHD Care

IHD as a Continuum

Risk factors:(e.g. hypertensionand hyperlipidemia)

Coronary artery disease:i.e., acute coronary syndromes andTreatment including PCI

Sequelae of CAD:i.e., CHF and chronic therapiesAnd device therapy (ICD)

Asymptomatic

Asymptomatic persons

without known Ischemic

Heart Disease

Stable Angina or Low Risk

Unstable Angina*

Acute Coronary Syndromes

Patients with known Ischemic

Heart Disease

Non-cardiac chest pain

New onset chest pain

Sudden Cardiac Death

Non-invasiveTesting

IHD as a Clinical Continuum

Strategic focus

Strategic foci

IHD QUERI Goals

Proposed projects

•Leveraging systems of care•Emphasis on effectiveness and safety•Team-based, patient-centered, coordinated care•Longitudinal care

Focus on systems of care and strategic partnerships as opposed to specific clinical conditions. Integrations with VHA strategic objectives.

Goal 1: Leverage information systems to improve quality and safety of care

1. Improve availability of timely clinical information at point of decision making

2. Track changes in quality of care and outcomes for AMI

3. Develop implementation tools and interventions at program level

4. Identify organization factors association with utilization of clinical data

Objective 1-1: Improve availability of timely clinical information at point of decision making

• Example: Appropriateness of PCI– Validate data elements in

CART needed to make appropriateness classification

– Assess variation in appropriateness of PCI

APCI-RRP and Bradley CDA

Objective 1-2: Track changes in quality of care and outcomes for AMI

• Longitudinal effectiveness and safety– Bleeding from triple

anti-thrombotic therapy– Prevalence, care, and

outcomes of newly diagnosed diabetes

– Clopidogrel use in CKD patients

IHAMI and CCFCS

Objective 1-3:Develop implementation tools and interventions

• Example: Reducing

radiation dose for invasive cardiac procedures– Develop toolkit to

reduce radiation used for invasive cardiac procedures

– Pilot test toolkit at 2 VA cath labs

Radiation-RRP

Objective 1-4: Identify organizational factors association with utilization of clinical data

• Example: ORCA– Prospectively validate

measure of organizational readiness to change against operationally-relevant outcomes

– Emphasis factors that are actionable

– Collaboration among 4 QUERIs

ORCA

Goal 2: Improve cardiovascular risk factor management by integrating new programs into

evolving systems of care

1. Identify and understand differences in risk factor management and their causes

2. Identify organizational and contextual factors that influence risk factor management

3. Develop implementation tools and interventions at program level to improve care and efficiency

Objective 2-1: Understand differences in risk factor management and causes

• Determine BP and LDL control in year following catheterization among CAD patients

• Determine specific patient, provider, and system factors associated with BP and LDL control

Maddox CDA

Objective 2-2: Identify organizational and contextual factors that influence risk factor

management• Example: Organizational

correlates of medication adherence– Assess roles of organization,

provider and patient-level factors in medication adherence

– Specifically examines structural factors thought to improve adherence (e.g., pharmacy FTE)

OCAM

Objective 2-3: Develop implementation tools and interventions at program level to improve

care and efficiency

• Develop intervention toolkit

• Incorporates formative evaluation focusing on contextual factors

• Collaboration with Stroke QuERI

• Develop and test centralized call center to support SMILE-BP intervention

• Addresses needs of smaller facilities with limited resources

SMIIIR

SMILE-BPRRP

VALUE SDP

• Demonstrated telephone-based staged matched intervention improved BP control

IHD-QUERI Goals: Next 3-5 Years

Leveraging established platforms for current projects

CART and CCFCS and IHD-QUERI partnerships and collaborations

Maddox CDA SMILE BP Clopidogrel RRPAPCI-RRP

ORCA OCAMRadiation RRP

Example of Innovative Work Leveraging Established Platforms

Clopidogrel-RRP

Link information systems (i.e., CART-CL and pharmacy) to provide real-time decision support and safety alerts

Real-time Assessment of Whether Clopidogrel is Filled at Hospital Discharge

Leveraging Collaborations with Partners

IHD QuERI Research Coordinating Center

Seattle, WA

IHD QuERI Clinical Coordinating Center

and VA REAPDenver, CO

Jeffrey WhittleAffiliate Investigator

Milwaukee, WI

Sundar NatarajanAffiliate Investigator

New York, NY

Michael FischerInvestigatorChicago, IL

Salim ViraniAffiliate Investigator

Houston, TX

Cynthia JackeviciusAffiliate Investigator

Los Angeles, CA

Paul HeidenreichCHF QuERI

Palo Alto, CA

Michael Ho, Thomas Maddox, Tom TsaiAffiliate Investigators

Denver, CO

Stroke QuERIIndianapolis, IN

Mental Health QuERILittle Rock, AR

Diabetes QuERIAnn Arbor, MI

VA PCS, ACC/NCDR, FDANational Device Surveillance Center

Washington, DC

PACT Evaluation Centerand QIR

Seattle, WA Anne SalesVA IPEC

Michigan

Future Projects Leveraging Collaborations with Partners

Project to Study Implementation of CART-Eletrophysiology: Leverage Operational

Partnerships

CART-EP SDP

NCDR-ICD registry

National Cardiac Device

Surveillance Program

CART/PCS

Project to Improve Transitions of Care: Leverage Operational and QUERI Partnerships

Transitions-RRP

CHF QUERI

PACTQIR -Predictve

modeling & care

management

IHD QUERI

New Members of IHD-QUERI

• Co-Clinical Coordinator– Mike Ho

• Administrative Coordinator and Co-Implementation Research Coordinator– Blake Wood

• New investigators/EC committee members– Tom Tsai (interventional cardiologist) Paul Varosy

(electrophysiologist), Steve Bradley (general cardiologist), Sundar Natarajan (internist) Paul Hebert (health economist), Anne Sales (nurse) and Cynthia Jackevicius (pharmacist)

Summary Accomplishments to date

• Productivity• Innovative projects• Extensive network of partners

Implementation Strategy ≈ Strategic Plan• Focus on systems of care

Appendices and additional slides