VHA's Priorities for Strategic Action
Spotlight: High-Performance Healthcare Network in Depth
The following three articles represent some of the important HSR&D research related to high-performing healthcare networks.
Unlearning and the Challenge of De-implementation
David Aron, MD, MS
The practice of medicine is an ever changing field. Clinicians must keep abreast of new discoveries and unlearn what has been shown to be incorrect. In contrast to the large literature on the adoption of new practices and technologies, there is little about what it takes to discontinue a common and routine practice, such as overuse of low value (and potentially harmful) care. The Choosing Wisely Campaign was launched several years ago by the American Board of Internal Medicine Foundation to address low-value care, and now involves numerous specialty societies both in medicine and in other fields. A recent population-level analysis of seven low-value services found a desirable decrease for two recommendations (imaging for headache and cardiac imaging for low-risk patients), but effect sizes were marginal (Rosenberg, et al, 2015). Thus, despite national attention and increasing evidence, the overuse of low-value care persists.
Critical issues of overuse of low-value practices and medication safety intersect with the over-treatment of diabetes. In particular, over-intensive glycemic control increases morbidity and mortality due to hypoglycemia risk without providing meaningful benefits for certain patient groups. Our work has shown that over-treatment may occur in up to 50% of patients with diabetes who are at high risk for hypoglycemia - due to use of hypoglycemic agents, age, and/or significant comorbidities , as defined by an A1c <7% target. National recognition for hypoglycemic safety is evidenced by the creation of a Health and Human Services Federal Interagency Workgroup (with representatives from VA and DoD) to address adverse drug events, including those from hypoglycemic agents. Moreover, the Choosing Wisely initiative to reduce low-value care includes an American Geriatric Society recommendation to "not treat most persons over 65 years of age with medications to reduce the A1c<7.5%."
VHA's Choosing Wisely initiative, which included hypoglycemic safety as one of its targeted conditions, was launched in late 2014. The focus of our HSR&D study is the concomitant processes of de-implementation of clinically inappropriately tight glycemic control and the implementation of hypoglycemia risk reduction. If awareness is a critical piece of practice adoption, early results from our study are sobering. A survey of key informants at VA healthcare facilities indicated that only 55% were aware of the initiative. This survey was by no means comprehensive. Nevertheless, some facilities and VISNs have been particularly active and shown some promising results. We are in the process of identifying high-performing VA sites to determine what factors - and what configurations (combinations) of factors characterize those sites.
The task of identifying high performers turns out to be more complicated than it appears on the surface. Although identification of positive deviants in community health studies is relatively easy, the situation is quite different with organizational positive deviance. In the latter case, there is no agreement on the criteria for positive deviance. This led to an ancillary project to compare different ways of identifying positive deviance. This is another example of how one research finding leads to more research. Because models of implementation science grant applications are hard to come by, we published the grant so that interested individuals might benefit from our lessons learned (Aron, et al, 2014). The identification of over-treatment was only the latest result of a long-standing collaboration between Drs. David Aron and Len Pogach (National Program Director for Diabetes), with each project leading to another.1,2 This work also has informed policy both within and outside VA.
Sherry Ball, PhD
Louis Stokes Cleveland VA Medical Center
David Aron, MD, MS
VA HSR&D Quality Enhancement Research Initiative (QUERI)
1. Pogach L and Aron D. Sudden acceleration of diabetes quality measures. JAMA. February 16, 2011;305(7):709-10.
2. Pogach L and Aron D. The other side of quality improvement in diabetes for seniors: A proposal for an overtreatment glycemic measure. Archives of Internal Medicine. 2012;172(19):1510-12.
Breaking Down Geographic Barriers to Evidence-Based, Veteran-Centered Specialty Care for Veterans with Complex Mental Health Conditions
Mark Bauer, MD
Bipolar disorder affects more than 9,000,000 Americans each year, and more than 100,000 Veterans receive VA care for this disorder each year. Moreover, bipolar disorder is the single diagnosis most highly associated with completed suicide among Veterans. Evidence-based treatments exist, but are sub-optimally deployed in practice both within and beyond the VA healthcare system. Therefore, there is a need for innovative collaborative care models that will enhance quality and improve patient outcome for this complex disorder.
Upon joining VA in the early 1990s, Dr. Mark Bauer was struck by the high and growing, yet underestimated, prevalence of bipolar disorder among Veterans. He also was impressed that most treatment failures were due not to refractory illness (resistant to treatment), but rather to social and self-management determinants of healthcare. He and his colleagues reasoned that care management interventions could provide Veteran-centered care and improve health status for this growing population. Dr. Bauer's group was the first to adapt the Chronic Care Model (which they call the Collaborative Care Model, or CCM) to severe mental health conditions treated in mental health clinics. Through the ensuing years they operationalized, tested, refined and developed implementation strategies for the Bipolar CCM, supported by funding from HSR&D, the National Institutes of Health (NIH), and the Agency for Healthcare Research and Quality (AHRQ).
The first large-scale randomized controlled trial of the Bipolar CCM, sponsored by VA's Cooperative Studies Program (CSP), demonstrated sustained improvements in clinical outcomes, quality of life, satisfaction, and care quality—at no net treatment cost (Bauer et al, 2006). Parallel studies funded by the NIH established the applicability of the model to a large staff-model HMO, while HSR&D and VA's Clinical Science Research and Development (CSR&D) funding studies to broaden the applicability of the CCM to address comorbid cardiovascular health and improve outcome for Veterans with other serious mental health conditions (Miller et al, 2013; Woltmann E, et al). As a result, the Bipolar CCM was incorporated into the VA/DoD Practice Guidelines for the Management of Bipolar Disorder in Adults (2010), and has been listed on SAMHSA's prestigious National Registry of Evidence-Based Programs and Practices (NREPP, 2013).
However, adoption of the model requires a critical mass of Veterans with bipolar disorder, as well as providers with specialty expertise, in the same locale. In 2011, VA's Office Mental Health Operations, Patient Care Services/Mental Health Services, and the VA Office of Telehealth Services, part of VA Connected Health, approached Dr. Bauer to develop and implement a clinical video-conference-based format for the Bipolar CCM, thus overcoming the issue of critical mass and breaking down geographic barriers to specialty care access for this condition. To date, the Bipolar Telehealth program has received more than 750 consults and is active in 27 sites across eight VA regional networks. Analyses presented at the 2015 HSR&D National Meeting demonstrate significant improvement in health outcomes for program participants, including Veterans residing in rural settings and those treated at small community-based outpatient clinics (CBOCs).
VA research funding supported the development of this evidence-based, Veteran-centered intervention for a complex and highly morbid mental health condition, which requires specialty care. Partnership between operational leaders and health services researchers creatively and sustainably extended the innovation based on health system operational priorities. Research-operations partnerships can develop innovative solutions to high-priority system needs. As is the case with private industry, the time horizon for developing evidence-based products is not short, but the substantial infrastructure of VA's integrated healthcare system can achieve sustainable innovations that lead the way both for improvements in Veterans' health and for innovations taken up by other healthcare systems in the U.S. and abroad.
Mark Bauer, MD, is Associate Director of HSR&D's Center for Healthcare Organization and Implementation Research (CHOIR).
Promoting Effective, Routine, and Sustained Implementation of Psychotherapies for PTSD
Nina Sayer, PhD
The prevalence of post-traumatic stress disorder (PTSD) is estimated to be 9%-15% among Vietnam Veterans and 10%-20% among Veterans of the Iraq and Afghanistan wars. In 2006, VA began national rollouts of two evidence-based psychotherapies for PTSD - Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). Since that time, VA issued a policy requiring all Veterans with PTSD to have access to CPT or PE, and more than 4,600 VA clinicians have completed training (which involves both a workshop and weekly consultation), in these psychotherapies. However, available data indicates that CPT and PE are reaching only a small portion of Veterans with PTSD, even among those patients seen in specialty outpatient PTSD programs that are resourced to play a key role in delivery of CPT and PE. Evidence-based information on team/organization factorsassociated with the use of CPT and PE in outpatient programs could inform policy and implementation interventions to improve reach of these proven treatments to Veterans with PTSD who might benefit.
Led by Drs. Nina Sayer and Craig Rosen, the Promoting, Effective, Routine, and Sustained Implementation of Psychotherapies for PTSD (PERSIST) study seeks to:
- Identify organizational- and team-level factors that influence extent of use (reach) and sustainability of evidence-based psychotherapies for PTSD in specialized PTSD teams, as well as promising local innovations for overcoming barriers to implementing CPT and PE;
- Explore the relationship between patient characteristics, facility characteristics, team resources, and team process measures, and the sustainability of CPT and PE;
- Investigate the relationship between patient characteristics, facility characteristics, team resources, and measures of team process, and reach of CPT and PE; and
- Describe variation in the selection of patients for CPT and PE, sequencing of treatments, and modifications to standard CPT and PE protocols.
Participants in the PERSIST study include 99 to 135 staff from nine VA medical centers and associated CBOCs which vary in extent of use of CPT and PE, as well as 4 HSR&D Central Office stakeholders. Investigators are surveying and conducting site visit interviews with staff at these selected sites, including frontline providers on outpatient PTSD teams, referring providers from general mental health and primary care clinics, as well as VISN and facility leadership. VA administrative data is being used to characterize the extent to which PTSD teams are using CPT and PE as well as facility, PTSD team, and patient characteristics.
Based on national VA administrative data, preliminary findings indicate considerable regional and within-VISN variation in the extent of use of CPT and PE across VA outpatient PTSD teams. Site visit interviews also indicate differences between high- and lower-reach sites in the following areas:
- PTSD team mission and structure;
- Resources available for mental health services outside of the teams;
- Processes for patient engagement, outcome monitoring, and psychotherapy discharge; and
- Staff attitudes regarding the benefits for patients, the clinic and staff associated with CPT and PE.
Data collection and analysis are ongoing.
Nina Sayer, PhD
Deputy Director, HSR&D's Center for Chronic Disease Outcomes Research (CCDOR)
Craig Rosen, PhD
Deputy Director, National Center for PTSD, Dissemination & Training Division