June 2008

In This Issue:

• QUERI Projects Making a Difference
• New QUERI Collaborations
• QUERI Center Updates
• Recent QUERI Publications
• Special QUERI Series in Implementation Science

QUERI Projects Making a Difference

Addressing Barriers to Hypertension Treatment among Veterans with Diabetes

Diabetes Mellitus QUERI (DM-QUERI) investigators recently concluded the Addressing Barriers to Treatment (ABATe) study, which examined factors that influence the decision to initiate treatment change during a primary care visit in response to an elevated blood pressure in veterans with diabetes. Veterans (n= 1169) were enrolled in this study if their triage blood pressure (BP) prior to a primary care visit was >=140/90 mm Hg. Findings show that for about half of the veterans in this study who presented with a triage BP of 140/90 mm Hg or greater, providers initiated treatment change (medication intensification or planned close follow-up). The likelihood of treatment change increased substantially with higher systolic and diastolic BP at triage and higher systolic BP during the previous year. However, repeated BP measurement by providers during the visit (lower than initial reading) or veterans' reports of home BP lower than 140/90 mm Hg, as well as discussion of medication issues decreased the likelihood that antihypertensive medication would be intensified during the clinic visit.

Researchers suggest that perhaps the most actionable finding from this study is that rather than simply failing to act, providers were often confronted with the inherent clinical uncertainty about BP values and, thus, documented actions to incorporate additional information (e.g., repeating measurements or eliciting home blood pressure values). Unfortunately, they are doing so without a systematic approach, which could undermine performance improvement initiatives and may be an obstacle to optimizing management of hypertension and improving outcomes for high-risk populations. [Kerr E, Zikmund-Fisher B, Klamerus M, et al. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure: A cohort study. Annals of Internal Medicine May 2008;148(10):717-27.]

Expanding Cardiovascular Assessment and Reporting

Ischemic Heart Disease QUERI (IHD-QUERI) is part of a unique collaborative effort with VA Patient Care Services and the VHA Office of Information to monitor and evaluate how cardiac catheterization procedures (primary therapy for IHD) are used within the VA healthcare system. The Expanding the Cardiovascular Assessment, Reporting and Tracking System (CART) was developed to address the critical need for a systematic, system-wide method for tracking the use of diagnostic and interventional catheterization procedures. CART also is intended to improve clinical care and communication, monitor patient safety, and support clinical and health services research concerning cardiovascular procedures and diseases.

The CART application is integrated within VA's electronic health record, enabling providers to document care as part of routine clinical work. CART for Cardiac Catheterization Laboratories (CART-CL) tracks coronary procedures such as percutaneous coronary interventions and is mandated for use in all VA cath labs. Currently, VA is working with the FDA to designate CART-CL as a 'sentinel patient safety network' for cath lab device safety in the United States. In addition, CART-CPR is a planned enhancement to document in-hospital cardiac arrest, to provide point-of-care documents for providers, and to provide a foundation for quality improvement programs for cardiac arrest. For more information, contact CART Clinical Director John Rumsfeld, MD, PhD at john.rumsfeld@va.gov.

Improving Schizophrenia Treatment

A Study of Strategies to Improve Schizophrenia Treatment (ASSIST) tested methods to improve metabolic side-effect monitoring for veterans with psychosis. Two strategies were implemented - a team-based quality improvement (QI) approach versus an opinion leader (OL) strategy. Five VAMCs were randomized to Team QI, Team OL, or "usual care" study conditions. For Teams QI and OL, Mental Health-QUERI provided ongoing facilitation during the six-month implementation phase. The Team QI site increased the proportion of patients with recommended weight monitoring from 70% (baseline) to 93% (follow-up), with dramatically increased glucose and lipid monitoring (53% to 80% and 29% to 67%, respectively). At one OL site, monitoring rates increased substantially (weight: 80% to 88%; glucose: 48% to 63%; and lipids: 30% to 57%), while rates at the other OL site decreased. Usual care sites did not substantially increase monitoring rates during the study. Additional results indicate that designating a provider or clinic to ensure that monitoring is done, and a VISTA computer routine to identify patients due for monitoring, were effective QI components.

These findings are informing ongoing efforts to identify effective strategies to improve antipsychotic side-effect monitoring and management. For more information, contact Jeffrey L. Smith, MH-QUERI Implementation Research Coordinator, at Jeffrey.Smith6@va.gov.

Integrating System Redesign into Acute Stroke Care

VISN 11 network leaders recently partnered with Stroke-QUERI to coordinate the initial Stroke Summit - Collaborative Learning Session I. Multidisciplinary provider teams from several VA medical centers participated in this three-day learning workshop conducted in Indianapolis to gain knowledge and skills based on the philosophy of Lean Six Sigma. This philosophy includes the following basic concepts: Identify the processes most important to delivering customer value, map these processes, and identify any constraints.

With the assistance of Stroke-QUERI, Summit participants tailored the implementation of acute stroke care interventions for each site. The interventions target the following two JACHO (Joint Accreditation of Healthcare Organizations) indicators for the management of our veterans with acute stroke:

1. patients with ischemic or hemorrhagic stroke who undergo screening for dysphagia (difficulty swallowing) with simple, beside testing protocol before being given any food, fluids, or medication by mouth;
2. ischemic stroke patients with LDL>100 or LDL not measured, or who are on cholesterol-reducing medication prior to admission, or who are discharged on cholesterol reducing drugs. Additionally, each team is implementing standard acute stroke order sets and will be measuring the sustainability of their interventions on a continuum.

Stroke-QUERI will provide bi-weekly coaching to VISN 11 sites to facilitate implementation of this intervention. For more information, contact Teresa Damush, PhD, Stroke-QUERI Implementation Research Coordinator, at tdamush@iupui.edu.

New QUERI Collaborations

Chronic Heart Failure QUERI (CHF-QUERI) is collaborating with Ischemic Heart Disease QUERI (IHD-QUERI) and the Mental Health QUERI (MH-QUERI) on a recently funded project to test the effectiveness of a Patient-Centered Disease Management (PCDM) intervention for heart failure. The intervention centers on collaborative care, tele-monitoring, and embedded depression management in addition to CHF management. The research also is being conducted in collaboration with VA Patient Care Services and the Office of Care Coordination. For more information contact Anju Sahay, PhD, CHF-QUERI Implementation Research Coordinator, at anju.sahay@va.gov.

Chronic Heart Failure QUERI (CHF-QUERI) has formed the Heart Failure (HF) Provider Network in conjunction with Patient Care Services and Dr. Robert Jesse, National Program Director for Cardiology. Currently more than 360 providers from 167 facilities participate in the activities of the HF Network to improve the quality of care for veterans with CHF. Several facilities have reported substantial benefits based on this ongoing initiative. For more information contact Anju Sahay, PhD at anju.sahay@va.gov.

Chronic Heart Failure QUERI (CHF-QUERI) is collaborating with My HealtheVet on a project to provide all veterans with access to a heart failure health status survey that they can use to measure their current status, as well as print and bring with them to their clinic visits. Investigators also are building a tool for My HealtheVet that will allow veterans to determine if their care is consistent with current guideline recommendations. For more information contact Anju Sahay, PhD at anju.sahay@va.gov.

SCI-QUERI is working with the Birmingham SCI Model Systems program on an educational campaign of smoking's effects on secondary complications of spinal cord injury. An educational video and informational brochure focusing on the higher risk factors and additional health consequences that smoking has on select secondary medical complications associated with spinal cord injury and disease will be produced and widely disseminated. For more information contact Phil Ullrich, PhD, SCI-QUERI Implementation Research Coordinator, at phillip.ullrich@med.va.gov.

QUERI Center Updates

Chronic Heart Failure QUERI has initiated the Heart Failure Provider Network - a network of providers interested in improving heart failure care throughout the VA healthcare system. This Network is an important mechanism for the implementation of interventions that will improve the health and healthcare for veterans with heart failure. For more information about joining the Heart Failure Provider Network, contact Anju Sahay, PhD at anju.sahay@va.gov.

Diabetes Mellitus QUERI is working to improve blood pressure management in veterans through better patient self-management and clinical medication management. Building off of the ABATe study, which found barriers to medication intensification within primary care, the Adherence and Intensification of Medications (AIM) program is designed to proactively identify veterans with diabetes and high blood pressure, in addition to either medication adherence problems or lack of adequate intensification. These patients will receive medication counseling and management by a specially trained clinical pharmacist. This implementation study will involve three VA sites and two sites at Kaiser Permanente in Northern California. For more information about DM-QUERI, visit http://www.diabetesqueri.research.va.gov/, or contact Leah Gillon, MSW at leah.gillon@va.gov.

HIV/Hepatitis QUERI is working to increase screening for veterans at risk of HIV through several strategies that include assessing organizational readiness to adopt nurse-based HIV rapid-testing, utilizing clinical reminders to alert providers when seeing at-risk veterans that need to be tested, and reducing test result wait times by using rapid-testing techniques. Better screening can lead to early treatment and improved patient outcomes. Viral hepatitis initiatives include improving self-management skills for Hepatitis C patients, and assessing the impact of integrated care on hepatitis treatment. For more information, contact Randal Henry, DrPH at stephen.henry@va.gov, or visit their website at http://www.va.gov/queri-hiv/ .

Ischemic Heart Disease QUERI is working with VA's Patient Care Services, the Office of Quality and Performance, and the Office of Information on a national VA reporting system for procedures performed in VA cardiac catheterization clinics. The Cardiovascular Assessment, Reporting and Tracking System for Cardiac Catheterization Laboratories (CART-CL) tracks coronary procedures such as percutaneous coronary interventions, which serve as the primary therapy for ischemic heart disease. CART-CL is installed or in the process of installation at all 75 VA cath labs. For more information, contact the CART-CL Clinical Director, John Rumsfeld, MD, PhD at john.rumsfeld@va.gov .

Mental Health QUERI developed Translating Initiatives for Depression into Effective Solutions (TIDES) - a depression collaborative care model. A key feature of TIDES is collaboration between primary care providers and mental health specialists supported by a depression care manager. TIDES implementation at seven demonstration clinics enabled 8 out of 10 depressed patients to be treated effectively in primary care. TIDES collaborative care is currently being spread to new clinics across VA through Primary Care/Mental Health integration initiative funding from the Office of Mental Health Services. For more information about the TIDES program or other MH-QUERI research, contact Jeff Smith (PhD candidate) at Jeffrey.smith6@va.gov.

Comprehensive TIDES materials can be found at http://vha22web6/sites/Research/HSRD/ClinicalPart/default.aspx (VA access only).

Polytrauma/ Blast-Related Injuries QUERI has formed a family care collaborative with the four VA Polytrauma Rehabilitation Centers (PRCs) to promote family-centered care, standardize family care across and within all the PRCs, and optimize outcomes for family members of severely injured soldiers. The PT/BRI Family Care Map collaborative developed a web-based tool to help family members understand the rehabilitation process and their role as part of the care team. The Family Care Map (FCM) begins with the transition from the Military Treatment Facility, when the family is referred to a PRC and introduced to the team and facility. The FCM provides information about what will happen during the rehabilitation process from before admission to after discharge, across all four PRCs. The website includes reference materials, such as the Polytrauma Family Education Manual, as well as links to external references. The tool is being piloted at the four PRCs for six months. For more information about this project, contact Carmen Hall, RN, PhD at carmen.hall@va.gov.

Spinal Cord Injury QUERI has projects underway to examine current patterns for the management of respiratory conditions including COPD, pneumonia, and sleep apnea, use of telehealth to help treat skin conditions, development of an SCI-specific tool for obesity assessment and patient education materials for weight management, and the development of an SCI-specific condition center for MyHealtheVet. SCI-QUERI also expects to begin a study that combines guideline-recommended, patient-focused strategies to reduce the variability in ulcer management strategies among providers. For more information, contact Phil Ullrich, PhD at philip.ullrich@va.gov.

Stroke QUERI is performing a needs assessment on stroke patients and their family members' perception of home-telehealth services that enable a clinician and/or their caregiver to maintain direct communication. The VA is a recognized leader in the development and implementation of home-telehealth services, and this project will help create in-home messaging devices specifically designed for veterans who have survived a stroke. For more information about this project, contact Neale Chumbler, PhD at neale.chumbler@med.va.gov.

Substance Use Disorders QUERI is working with clinical partners in VA to implement evidence-based management of alcohol misuse nationwide. SUD-QUERI is involved in multiple efforts to implement routine brief alcohol counseling and specialty care referral, when indicated for veterans who screen positive for alcohol misuse. For more information about this project, contact Katharine Bradley, MD at Katharine.bradley@va.gov.

1. Evans C, LaVela S, and Weaver F, et al. Epidemiology of hospital-acquired infections in veterans with spinal cord injury and disorder. Infection Control and Hospital Epidemiology 2008;29(3):234-242.
2. Friedemann-Sanchez G, Sayer N, and Pickett T. Provider perspectives on the inpatient rehabilitation for polytrauma patients. Archives of Physical Medicine and Rehabilitation January 2008;89(1)171-178.
3. Guihan M, Garber S, and Bombardier C, et al. Lessons learned while conducting research on prevention of pressure ulcers in veterans with spinal cord injury. Archives of Physical Medicine and Rehabilitation July 2007;88(7):858-861.
4. LaVela S, Smith B, and Weaver F. Perceived risk for influenza in persons with spinal cord injuries and disorders. Rehabilitation Psychology 2007;52:458-462.
5. Sayer N, Chiros C, and Sigford B, et al. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the global war on terror. Archives of Physical Medicine and Rehabilitation January 2008;89(1)163-70.
6. Sigford B. "To care for him who shall have borne the battle and for his widow and his orphan" (Abraham Lincoln): The Department of Veterans Affairs Polytrauma System of Care. Archives of Physical Medicine and Rehabilitation January 2008;89(1): 160-162.
7. Ullrich P, Jensen M, Loeser J, and Cardenas D. Catastrophizing mediates associations between pain, psychological distress, and functional disability among persons with spinal cord injury. Rehabilitation Psychology 2007;52:390-398.
8. Wallace C and Legro M. Using formative evaluation in an implementation project to increase vaccination rates in high-risk veterans: QUERI Series. Implementation Science 2008 Apr 22;3(1):22.

Implementation Science, an open-access online journal, is currently featuring a series of articles documenting QUERI's progress and lessons learned. Articles include:

• "Measuring Persistence of Implementation" by Candice Bowman, Elisa Sobo, Steven Asch, and Allen Gifford.
• EQUIP: Implementing Chronic Care Principles and Applying Formative Evaluation Methods to Improve Care for Schizophrenia" by Alison Brown, Amy Cohen, and Mathew Chinman, et al.
• "Human Subjects Protection Issues in QUERI Implementation Research" by Edmund Chaney, Laura Rabuck, and Jane Uman, et al.
• "A Process for Developing an Implementation Intervention" by Geoffrey Curran, Snigda Mukherjee, Elise Allee, and Richard Owen.
• "Implementing and Evaluating a Regional Strategy to Improve Testing Rates in VA Patients at Risk for HIV, Utilizing the QUERI Process as a Guiding Framework" by Matthew Goetz, Candice Bowman, and Tuyen Hoang, et al.
• "Improving Eye Care for Veterans with Diabetes: An Example of Using the QUERI Steps to Move from Evidence to Implementation" by Sarah Krein, Steven Bernstein, and Carol Fletcher, et al.
• "The role of implementation in the QUERI program" by Mark Smith and Paul Barnett.
• "Overview of the VA Quality Enhancement Research Initiative" by Cheryl Stetler, Brian Mittman, and Joseph Francis.
• "Using Formative Evaluation in an Implementation Project to Increase Vaccination Rates in High-Risk Veterans" by Carolyn Wallace and Marcia Legro.

To view these articles, please go to http://www.implementationscience.com.