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Implementing the
Findings of
Comparative
Effectiveness Research
David Atkins MD, MPHDirector, QUERI Program
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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
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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.
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Copyright restrictions may apply.
Dougherty, D. et al. JAMA 2008;299:2319-2321.
The 3 Translational Blocks
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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?
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
-
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Bridging theTranslation Gap
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