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SDR 96-002 – QUERI Project

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SDR 96-002
Ambulatory Care Quality Improvement (ACQUIP)
Stephan D. Fihn MD MPH
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: April 1996 - February 2001

BACKGROUND/RATIONALE:
Health care organizations, including the VA, are investing substantial effort to improve quality of care. As part of this process, greater emphasis is being placed on measurement of outcomes, and in particular, functional outcomes and satisfaction as reported by patients.

OBJECTIVE(S):
ACQUIP was designed to determine whether quality and outcomes of health care improve when primary care providers have access to regular assessments of their patients' health and function along with routine clinical data and information about clinical guidelines.

METHODS:
This study was a randomized trial conducted at the General Internal Medicine Clinics of seven VA facilities. Each participating GIMC is organized into discrete firms staffed by different groups of providers who care for different patients. One randomly selected firm received the intervention and one served as control. Patients who made at least one GIMC visit in the last year were eligible to participate. Patients were surveyed at baseline to determine active medical problems. Subsequent mailings included a general evaluation of health status (SF-36), a satisfaction questionnaire and, as appropriate, one of six condition-specific questionnaires: the Seattle Angina Questionnaire, the Seattle Obstructive Lung Disease Questionnaire, the Hopkins Symptom Checklist (depression), and questionnaires regarding diabetes, drinking, and hypertension. Clinical/utilization data were downloaded weekly from VISTA and supplemented with data from Austin. The intervention consisted of multi-faceted reports to patients' primary care providers (at the time of patient visits) showing trended physiologic and health status data and guideline-derived recommendations. Clinicians also received periodical reports displaying trends in the health status and satisfaction of their patients compared with their clinic as a whole. Reports were supplemented by training on QI and health status measures.

FINDINGS/RESULTS:
A total of 62,487 patients met the enrollment criteria, and were sent a screening questionnaire. Of these, 38,642 (62%) responded. Patients had a mean of 2.2 of six target conditions: angina (32%), depressive symptoms (30%), diabetes (23%), hypertension (55%), lung disease (23%), and "at risk" drinking (27%). Sixty-two percent of baseline responders returned follow-up, condition-specific questionnaires. During the two-year trial, a total of 44,014 customized feedback reports representing 10,905 patients were delivered to providers in intervention firms.

IMPACT:
The study is expected to provide important information about the utility of routine assessment of health status in clinical practice. If the findings support a clinically important difference, similar systems could be incorporated into national information systems. Instruments developed for this study have been well received and are presently being used in ongoing clinical trials at other institutions. The SAQ was adopted by the Medical Outcomes Trust and translated into several languages. The survey methods and extensive database developed have proven to be a valuable resource for VA researchers and administrators.

PUBLICATIONS:

Journal Articles

  1. Fan VS, Bridevaux PO, McDonell MB, Fihn SD, Besser LM, Au DH. Regional variation in health status among chronic obstructive pulmonary disease patients. Respiration; International Review of Thoracic Diseases. 2011 Jan 1; 81(1):9-17.
  2. Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, Ho PM, Kosiborod MN, Masoudi FA, Nallamothu BK, American College of Cardiology/American Heart Association Task Force on Performance Measures, American Academy of Family Physicians, American College of Emergency Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, Society of Hospital Medicine. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to develop performance measures for ST-elevation and non-ST-elevation myocardial infarction): developed in collaboration with the American Academy of Family Physicians and the American College of Emergency Physicians: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, and Society of Hospital Medicine. Circulation. 2008 Dec 9; 118(24):2596-648.
  3. Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, Ho PM, Kosiborod MN, Masoudi FA, Nallamothu BK, American College of Cardiology/American Heart Association Task Force on Performance Measures, American Academy of Family Physicians, American College of Emergency Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, Society of Hospital Medicine. ACC/AHA 2008 performance measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Performance Measures for ST-Elevation and Non-ST-Elevation Myocardial Infarction) Developed in Collaboration With the American Academy of Family Physicians and American College of Emergency Physicians Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, Society for Cardiovascular Angiography and Interventions, and Society of Hospital Medicine. Journal of the American College of Cardiology. 2008 Dec 9; 52(24):2046-99.
  4. Bryson CL, Au DH, Sun H, Williams EC, Kivlahan DR, Bradley KA. Alcohol screening scores and medication nonadherence. Annals of internal medicine. 2008 Dec 2; 149(11):795-804.
  5. Bryson CL, Au DH, Young B, McDonell MB, Fihn SD. A refill adherence algorithm for multiple short intervals to estimate refill compliance (ReComp). Medical care. 2007 Jun 1; 45(6):497-504.
  6. Parimon T, Chien JW, Bryson CL, McDonell MB, Udris EM, Au DH. Inhaled corticosteroids and risk of lung cancer among patients with chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine. 2007 Apr 1; 175(7):712-9.
  7. Au DH, Kivlahan DR, Bryson CL, Blough D, Bradley KA. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcoholism, clinical and experimental research. 2007 Mar 1; 31(3):443-51.
  8. Davis GE, Bryson CL, Yueh B, McDonell MB, Micek MA, Fihn SD. Treatment delay associated with alternative medicine use among veterans with head and neck cancer. Head & neck. 2006 Oct 1; 28(10):926-31.
  9. Liu CF, Campbell DG, Chaney EF, Li YF, McDonell M, Fihn SD. Depression diagnosis and antidepressant treatment among depressed VA primary care patients. Administration and policy in mental health. 2006 May 1; 33(3):331-41.
  10. DeSalvo KB, Fan VS, McDonell MB, Fihn SD. Predicting mortality and healthcare utilization with a single question. Health services research. 2005 Aug 1; 40(4):1234-46.
  11. Fan VS, Reiber GE, Diehr P, Burman M, McDonell MB, Fihn SD. Functional status and patient satisfaction: a comparison of ischemic heart disease, obstructive lung disease, and diabetes mellitus. Journal of general internal medicine. 2005 May 1; 20(5):452-9.
  12. Keeffe B, Subramanian U, Tierney WM, Udris E, Willems J, McDonell M, Fihn SD. Provider response to computer-based care suggestions for chronic heart failure. Medical care. 2005 May 1; 43(5):461-5.
  13. Fan VS, Burman M, McDonell MB, Fihn SD. Continuity of care and other determinants of patient satisfaction with primary care. Journal of general internal medicine. 2005 Mar 1; 20(3):226-33.
  14. Au DH, Bryson CL, Fan VS, Udris EM, Curtis JR, McDonell MB, Fihn SD. Beta-blockers as single-agent therapy for hypertension and the risk of mortality among patients with chronic obstructive pulmonary disease. The American journal of medicine. 2004 Dec 15; 117(12):925-31.
  15. Arterburn DE, McDonell MB, Hedrick SC, Diehr P, Fihn SD. Association of body weight with condition-specific quality of life in male veterans. The American journal of medicine. 2004 Nov 15; 117(10):738-46.
  16. Au DH, Udris EM, Curtis JR, McDonell MB, Fihn SD. Association between chronic heart failure and inhaled beta-2-adrenoceptor agonists. American heart journal. 2004 Nov 1; 148(5):915-20.
  17. Bridevaux IP, Bradley KA, Bryson CL, McDonell MB, Fihn SD. Alcohol screening results in elderly male veterans: association with health status and mortality. Journal of the American Geriatrics Society. 2004 Sep 1; 52(9):1510-7.
  18. Burman ML, Kivlahan D, Buchbinder M, Broglio K, Zhou XH, Merrill JO, McDonell MB, Fihn SD, Bradley KA. Alcohol-related advice for Veterans Affairs primary care patients: Who gets it? Who gives it? Journal of Studies On Alcohol. 2004 Sep 1; 65(5):621-30.
  19. Ohldin A, Young B, Derleth A, McDonell M, Diehr P, Kiefe C, Fihn S. Ethnic differences in satisfaction and quality of life in veterans with ischemic heart disease. Journal of the National Medical Association. 2004 Jun 1; 96(6):799-808.
  20. Reiber GE, Au D, McDonell M, Fihn SD. Diabetes quality improvement in Department of Veterans Affairs Ambulatory Care Clinics: a group-randomized clinical trial. Diabetes Care. 2004 May 1; 27 Suppl 2:B61-8.
  21. Smith NL, Chen L, Au DH, McDonell M, Fihn SD. Cardiovascular risk factor control among veterans with diabetes: the ambulatory care quality improvement project. Diabetes Care. 2004 May 1; 27 Suppl 2:B33-8.
  22. Bradley KA, Kivlahan DR, Zhou XH, Sporleder JL, Epler AJ, McCormick KA, Merrill JO, McDonell MB, Fihn SD. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcoholism, clinical and experimental research. 2004 Mar 1; 28(3):448-55.
  23. Fan VS, Au DH, McDonell MB, Fihn SD. Intraindividual change in SF-36 in ambulatory clinic primary care patients predicted mortality and hospitalizations. Journal of clinical epidemiology. 2004 Mar 1; 57(3):277-83.
  24. Fihn SD, McDonell MB, Diehr P, Anderson SM, Bradley KA, Au DH, Spertus JA, Burman M, Reiber GE, Kiefe CI, Cody M, Sanders KM, Whooley MA, Rosenfeld K, Baczek LA, Sauvigne A. Effects of sustained audit/feedback on self-reported health status of primary care patients. The American journal of medicine. 2004 Feb 15; 116(4):241-8.
  25. Fan VS, Bryson CL, Curtis JR, Fihn SD, Bridevaux PO, McDonell MB, Au DH. Inhaled corticosteroids in chronic obstructive pulmonary disease and risk of death and hospitalization: time-dependent analysis. American journal of respiratory and critical care medicine. 2003 Dec 15; 168(12):1488-94.
  26. Spertus JA, Dewhurst TA, Dougherty CM, Nichol P, McDonell M, Bliven B, Fihn SD. Benefits of an "angina clinic" for patients with coronary artery disease: a demonstration of health status measures as markers of health care quality. American heart journal. 2002 Jan 1; 143(1):145-50.
  27. Bradley KA, Maynard C, Kivlahan DR, McDonell MB, Fihn SD. The relationship between alcohol screening questionnaires and mortality among male veteran outpatients. Journal of Studies On Alcohol. 2001 Nov 1; 62(6):826-33.
  28. Diehr P, Patrick DL, Spertus J, Kiefe CI, McDonell M, Fihn SD. Transforming self-rated health and the SF-36 scales to include death and improve interpretability. Medical care. 2001 Jul 1; 39(7):670-80.
  29. Felker B, Katon W, Hedrick SC, Rasmussen J, McKnight K, McDonnell MB, Fihn SD. The association between depressive symptoms and health status in patients with chronic pulmonary disease. General hospital psychiatry. 2001 Mar 1; 23(2):56-61.
  30. Spertus JA, McDonell M, Woodman CL, Fihn SD. Association between depression and worse disease-specific functional status in outpatients with coronary artery disease. American heart journal. 2000 Jul 1; 140(1):105-10.
  31. Bradley KA, McDonell MB, Bush K, Kivlahan DR, Diehr P, Fihn SD. The AUDIT alcohol consumption questions: reliability, validity, and responsiveness to change in older male primary care patients. Alcoholism, clinical and experimental research. 1998 Nov 1; 22(8):1842-9.
  32. Henderson WG, Demakis J, Fihn SD, Weinberger M, Oddone E, Deykin D. Cooperative studies in health services research in the Department of Veterans Affairs. Controlled clinical trials. 1998 Apr 1; 19(2):134-48.
  33. Tu SP, McDonell MB, Spertus JA, Steele BG, Fihn SD. A new self-administered questionnaire to monitor health-related quality of life in patients with COPD. Ambulatory Care Quality Improvement Project (ACQUIP) Investigators. Chest. 1997 Sep 1; 112(3):614-22.
  34. Reiber GE, McDonell MB, Schleyer AM, Fihn SD, Reda DJ. A comprehensive system for quality improvement in ambulatory care: assessing the quality of diabetes care. Patient education and counseling. 1995 Sep 1; 26(1-3):337-41.
  35. Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Prodzinski J, McDonell M, Fihn SD. Development and evaluation of the Seattle Angina Questionnaire: a new functional status measure for coronary artery disease. Journal of the American College of Cardiology. 1995 Feb 1; 25(2):333-41.
  36. Spertus JA, Winder JA, Dewhurst TA, Deyo RA, Fihn SD. Monitoring the quality of life in patients with coronary artery disease. American Journal of Audiology. 1994 Dec 15; 74(12):1240-4.
Journal Other

  1. Kiefe CI, McDonell MB, Martin D, Fihn S. Patient satisfaction and perceived health status: general and coronary artery disease specific racial differences among veterans [abstract]. [Abstract]. Abstract book / Annual Meeting. Association for Health Services Research. Meeting. 1997 Oct 15; 14P70:70.
Book Chapters

  1. Reiber GE, McDonell MB, Schleyer AM, Fihn SD, Reda D. A Comprehensive System for Quality Improvement in Ambulatory Care. In: Assal J, Golay A, Jisser A, editors. New Trends in Patient Education. Amsterdam, Netherlands: Elsevier; 1999.
Conference Presentations

  1. Fihn SD, Bryson CL, McDonell MB, Fan VS. Effect of Reporting Worrisome Results to Primary Care Providers on Processes and Outcomes of Care. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  2. Diehr P. Performance of the PCTD in longitudinal studies using the SF-36 where there are deaths. Paper presented at: VA HSR&D National Meeting; 2002 Feb 14; Washington, DC.
  3. Diehr P. Performance of the PCTD in longitudinal studies using the SF-36 where there are deaths. Paper presented at: Health Policy Research Annual International Conference; 2001 Dec 1; Washington.
  4. Fan V, Au D, Heagerty P, Deyo R, McDonell M, Fihn S. Validation of Case-Mix Measures Derived From Self-Reports of Diagnoses and Health. Paper presented at: Society of General Internal Medicine Annual Meeting; 2001 May 1; San Diego, CA.
  5. Micek M, Braddock C, Bradley K, Diehr P, McDonell M, Fihn S. Patient characteristics associated with alternative medicine use among veterans attending outpatient VA General Medicine Clinics. Paper presented at: Society of General Internal Medicine Annual Meeting; 2001 May 1; San Diego, CA.
  6. Cody M. Improving mental health care in the nursing home. Paper presented at: National Institute of Mental Health Mental Health Services Research Annual Conference; 2001 Apr 26; Pear River, NY.
  7. Bradley K, Bush K, Kivlahan D, McDonell M, Fihn S. Two variations of recommended alcohol screening questionnaires did not improve screening accuracy in a VA general medical population. Paper presented at: VA HSR&D National Meeting; 2001 Feb 1; Washington, DC.
  8. Bradley K, Sporleder J, Kivlahan D, Burman M, McDonell M, Fihn S. VA primary care patients who screen positive for at-risk drinking: the relationship of readiness to change to severity of alcohol-related problems. Paper presented at: VA HSR&D National Meeting; 2001 Feb 1; Washington, DC.
  9. Bradley K, Sporleder J, Kivlahan D, Burman M, McDonell M, Fihn S. The association of prior alcohol treatment with severity and readiness to change at-risk drinking among VA general medical patients. Paper presented at: VA HSR&D National Meeting; 2001 Feb 1; Washington, DC.
  10. Bradley K. Evaluation of an alcohol screening program in female VA patients: A randomized controlled trial of provider feedback and prompting. Paper presented at: RWJ Foundation Generalist Physician Faculty Scholars Program National Annual Meeting; 2000 Dec 1; Carlsbad, CA.
  11. Young BA, Kiefe C, McDonell M, Au DH, Fihn S. Racial differences in satisfaction, quality of life and mortality in veterans with diabetes: the ambulatory care quality improvement project (ACQUIP). Paper presented at: VA HSR&D National Meeting; 2000 Mar 23; Washington, DC.
  12. Dahm C, Curtis JR, Fan VS, Au D, McDonell M, Burman ML. Association between satisfaction with providers' explanations about COPD and patients' coping skills. Paper presented at: American Thoracic Society Annual International Conference; 2000 Feb 16; Toronto, Canada.
  13. Spertus JA, McDonell M, Au D, Fan VS, Fihn SD. Health status and 2-year outcomes among veterans with coronary artery disease: results from the Ambulatory Care Quality Improvement Project (ACQUIP). Paper presented at: VA HSR&D National Meeting; 2000 Feb 16; Washington, DC.
  14. Udris E, McDonell M, Au D, Chen L, Tierney W, Fihn S. Case finding for computerized clinical reminders: To whom do the guidelines apply? Paper presented at: VA HSR&D National Meeting; 2000 Feb 16; Washington, DC.
  15. Anderson SM, McDonell MB, Canody CC, Schreiner SH, Fihn SD. Multi-hospital data mart for quality improvement in ambulatory care. Paper presented at: American Medical Informatics Association Annual Symposium; 1999 Sep 15; Washington, DC.
  16. Mirza SK, McDonell MB, Martin DM, Fihn SD. Validation of a computerized adaption of the Charlson Index using the SF36 among VA outpatients. Paper presented at: VA HSR&D National Meeting; 1999 Sep 15; Washington, DC.
  17. Kiefe CI, McDonell MB, Martin DM, Fihn SD. African-American veterans with coronary artery disease report worse heath and less satisfaction with care than Whites: results from the ACQUIP study. Paper presented at: Society of General Internal Medicine Annual Meeting; 1999 May 1; San Francisco, CA.
  18. McDonell MB, Marshall J, Fihn SD, Kilpatrick KE, Lessler DS. Measuring the job satisfaction of providers in VA primary care: The Seattle Provider Satisfaction Questionnaire (SPSQ). Paper presented at: Society of General Internal Medicine Annual Meeting; 1999 Apr 1; San Francisco, CA.
  19. Burman ML, McDonell MB, Fihn SD. Continuity of care as a determinant of patient satisfaction: results from the ACQUIP study. Paper presented at: VA HSR&D National Meeting; 1999 Feb 25; Washington, DC.
  20. Burman ML, McDonell MB, Fihn SD. Patient satisfaction among veterans varies by disease condition but not by symptom burden. Paper presented at: VA HSR&D National Meeting; 1999 Feb 15; Washington, DC.
  21. Fihn SD, McDonell MB. Variations in general and condition-specific health status among VA General Internal Medicine Clinics. Presented at: VA HSR&D National Meeting; 1999 Feb 15; Washington, DC.
  22. Kiefe CI, McDonell MB, Martin DM, Fihn SD. African-American veterans with coronary artery disease report worse heath and less satisfaction with care than Whites: results from the ACQUIP study. Paper presented at: VA HSR&D National Meeting; 1999 Feb 15; Washington, DC.
  23. McDonell MB, Marshall J, Fihn SD, Kilpatrick KE, Lessler DS. Measuring the job satisfaction of providers in VA primary care: The Seattle Provider Satisfaction Questionnaire (SPSQ). Paper presented at: VA HSR&D National Meeting; 1999 Feb 15; Washington, DC.
  24. Fihn SD, McDonell MB. Variations in condition specific health status among VA General Internal Medicine Clinics. Paper presented at: VA HSR&D National Meeting; 1998 Oct 15; Washington, DC.
  25. McDonell MB, Fihn SD, Anderson SM. Characteristics of respondents to initial and follow-up health status surveys. Paper presented at: VA HSR&D National Meeting; 1998 Feb 15; Washington, DC.
  26. Martin DM, McDonell MB, Fihn SD. Treatment assignment software and methods for randomization studies. Paper presented at: VA HSR&D National Meeting; 1998 Feb 1; Washington, DC.
  27. McDonell MB, Anderson SA, Fihn SD. The Ambulatory Care Quality Improvement Project: A multi-site information system for monitoring health outcomes. Paper presented at: VA HSR&D National Meeting; 1998 Feb 1; Washington, DC.
  28. Schleyer AM, McDonell MB, Fihn SD. Relationship between depression and impaired functional status in chronic obstructive pulmonary disease (COPD). Paper presented at: VA HSR&D National Meeting; 1998 Feb 1; Washington, DC.
  29. Spertus JA, Winder JA, Fihn SD, Dewhurst TA, Deyo RA. Assessing quality of life in patients with coronary artery disease: An alternative endpoint in outcome oriented clinical research. Paper presented at: American College of Cardiology Annual Scientific Session; 1994 Oct 15; Dallas, TX.
  30. Spertus JA, Winder J, Dewhurst T, Fihn SD, Deyo RA. Responsiveness of a new functional status measure to clinical change in patients with CAD. Paper presented at: American Heart Association Annual Scientific Sessions; 1993 Oct 15; Atlanta, GA.
  31. Spertus JA, Winder J, Fihn SD, Deyo RA. Validation of a functional status measure for patients with coronary artery disease. Paper presented at: American Heart Association Annual Scientific Sessions; 1993 Oct 15; Atlanta, GA.


DRA: Health Systems
DRE: none
Keywords: Functional status, Primary care
MeSH Terms: Health Status, Primary Health Care

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