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2019 HSR&D/QUERI National Conference Abstract

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4041 — Understanding clinical decision-making to de-implement low value care for pulmonary hypertension

Lead/Presenter: Megan McCullough,  COIN - Bedford/Boston
All Authors: McCullough MB (Center for Healthcare Organization and Implementation Research, Boston University School of Public Health ), Bolton R (Center for Healthcare Organization and Implementation Research,Brandeis University Heller School for Social Policy and Management), Solch, A (Center for Healthcare Organization and Implementation Research) Wiener, RS (Center for Healthcare Organization and Implementation Research, Boston University School of Medicine)

Objectives:
The low-value practice of prescribing pulmonary vasodilators for Groups 2 and 3 pulmonary hypertension (PH) is rising in VA, despite guidelines recommending against its use. We sought to uncover organizational and provider characteristics driving this inappropriate, costly, and potentially harmful practice to inform de-implementation efforts.

Methods:
We conducted a qualitative study at 3 VAMCs with high and 3 with low rates of pulmonary vasodilator prescribing for Groups 2/3 PH. Semi-structured interviews (N = 36) with key informants (clinicians, pharmacists, leadership) focused on organizational approaches and clinical decision-making around PH management. Interviews were analyzed thematically using inductive coding and constant comparison within and between high and low sites.

Results:
We found that clinical-decision making was influenced by 4 key domains: 1) Organizational Structure: Specialty PH clinics facilitated patient referral and prescribing of vasodilators. High sites often filled PH prescriptions initiated by community providers. Low sites managed PH patients in general pulmonary or cardiology clinics or referred to non-VA PH specialists. 2) Clinic Culture: Clinician deference to PH "experts" was dominant at high sites, while low sites used conservative approaches and team-based decision-making. 3) Evidence Interpretation: Specialists at high sites were liberal in interpreting the guidelines and evidence (including studies and their clinical experience) for Groups 2/3 PH, concluding that prescribing should be unconstrained. At low sites, specialists were more conservative, embracing guideline-concordant care. 4) Clinical Empathy: High site clinicians' desire to relieve symptoms of patients with severe PH led to a lower threshold to prescribe vasodilators. Clinicians at low sites felt pained watching patients decline, but believed that medications would not help or could even cause harm.

Implications:
This qualitative study identifies motivating factors for pulmonary vasodilator prescribing at high sites and factors that may mitigate overuse at low prescribing sites. De-implementation efforts should target both individual and organizational levels and will likely require cultural and structural changes.

Impacts:
The interaction between individual clinical decision-making and cultural prescribing practices at the site level influence low-value prescribing practices. While this study focused on pulmonary hypertension care, results highlight potential challenges of mitigating low-value care and may inform de-implementation initiatives in other clinical contexts.