BACKGROUND/RATIONALE:
Some 7.1 million Americans and an estimated 250,000 Veterans actively using VHA are myocardial infarction (MI) survivors. To date, most guideline interventions focus on a single patient condition but ambulatory post-MI patients are frequently more complex with multiple co-morbidities and conflicting guidelines applicable to them. The goal of VA MI-PLUS is to develop and test an Internet-delivered multi-modal guideline implementation strategy for the purpose of increasing provider adherence to guidelines for complex post-MI patients.

Often, quality improvement interventions are short-term with outcome measures limited to assessment of physician performance. We assessed whether our group randomized trial of a 2-year Internet-delivered intervention was successful. We randomized providers in CBOCs across the VA. Providers participated in a longitudinal education and performance improvement web-delivered intervention. We evaluated the impact of the intervention using patient data from the VA Austin data warehouse, and supplementary data from the VA External Peer Review Program (EPRP),

OBJECTIVE(S):
1) Identify barriers to provider adherence to guidelines within VHA clinics; 2) Apply guideline-based performance measures to electronic medical records (CPRS) and associated administrative data (EPRP); 3) Implement the interactive Internet intervention with VA-specific components, including performance feedback for CBOC clinicians; and 4) Test hypotheses on the intervention's effectiveness, and sustainability in the VA population.

METHODS:
We recruited 168 CBOCs and 401 providers representing 16,314 patients. Intervention providers received a multi-modal Internet-delivered intervention launched in 11/2004 and closed in 01/2007. Providers in intervention CBOCs received a longitudinal 27-month Internet-delivered intervention consisting of quarterly educational modules, clinical practice guidelines, and monthly literature summaries. The website was developed using service-oriented architecture and design principles refined in prior studies. Iterative usability sessions were used to refine the content. The core of the MI-Plus intervention was case-based education using interactive, Internet-delivered modules. Each case-based module reviewed the scientific evidence and relevant guidelines for the study clinical indicators; the format consisted of a series of questions with tailored feedback based on response. In total, 8 cases were provides over 27 months. The website included 1) a literature watch segment updated monthly with 1-3 reviews of recently published studies of high clinical impact and relevant literature; 2) a guidelines component with summaries of current guidelines applicable to post-myocardial infarction patients and links to the guidelines; 3) relevant practice tools and patient educational materials that could be downloaded. Providers in the control CBOCs were provided a link to a website with a list of guidelines supported by the VA Office of Quality and Performance and access to Internet-based education, but to adult medicine modules focused on post-MI patients without individual tailoring.

Outcomes consisted of 3 aspects of post-MI care: monitoring, treating, and changing of LDL and HbA1c levels. As stated outcome data was retrieved from Austin datasets and from Office of Quality Improvement External Peer Review Process chart abstraction. We identified all veterans with a VAMC discharge diagnosis of 410.xx or 412.xx between 2002-2008 who were treated at study CBOCs. We compared monitoring, treatment, and change in Blood Pressure, LDL and hemoglobin A1c across the pre- (2002-11/2004) and post-intervention (02/2007-2008) and adjusted for patient clustering.

FINDINGS/RESULTS:
Participating providers by randomization arm: 205 intervention and 196 control. Among intervention providers who logged on, the median time on was 6.3 months; 23.3% stayed involved over a 12 month period. VA providers were more likely to participate in this intervention as compared with providers in a similar NHLBI-funded study. Thus, interventions of this type may be especially valuable in VA.

In general, performance measures for monitoring and treating were quite high at baseline. Monitoring and treating of Blood pressure, LDL and HbA1c improved from pre- to post-intervention periods, generally more for intervention than control, but not significantly so.

We did find a significant difference for physiologic control. LDL levels decreased more in the intervention than control groups (18 vs. 14 mg/dl, P = 0.007). Among adults with diabetes, HbA1c levels decreased (-0.13%) in intervention but not in control (0.14%), P = 0.01. Using EPRP data, we found similar effects on LDL, but were not able to assess A1c. Data on blood pressure control was not available.


IMPACT:
Our study was successful in demonstrating a difference, favoring the intervention for some measures of patient control (LDL and A1c). However, traditional performance measures were ceiling out at baseline, and we were unable to demonstrate improvement. More nuanced performance measures are needed to detect change from interventions.

We used both EPRP and Austin data to analyze outcomes. It was reassuring that the two methods were in agreement for similar measures (such as lipid control), suggesting concurrent validity of EPRP and Austin data.

Carefully developed, longitudinal Internet-delivered educational interventions can lead to improvements in physiologic measures of cardiovascular risk factors. This intervention was effective in improving lipid and diabetes control among veterans with MI.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Bloch MJ, Basile JN. Analysis of Recent Papers in Hypertension. Journal of clinical hypertension (Greenwich, Conn.). 2009 May 1; 11(5):292-95. [view]
2. Cushman WC, Ford CE, Einhorn PT, Wright JT, Preston RA, Davis BR, Basile JN, Whelton PK, Weiss RJ, Bastien A, Courtney DL, Hamilton BP, Kirchner K, Louis GT, Retta TM, Vidt DG, ALLHAT Collaborative Research Group. Blood pressure control by drug group in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Journal of clinical hypertension (Greenwich, Conn.). 2008 Oct 1; 10(10):751-60. [view]
3. Schoen MJ, Tipton EF, Houston TK, Funkhouser E, Levine DA, Estrada CA, Allison JJ, Williams OD, Kiefe CI. Characteristics that predict physician participation in a Web-based CME activity: the MI-Plus study. The Journal of Continuing Education in The Health Professions. 2009 Jan 1; 29(4):246-53. [view]
4. Levine DA, Allison JJ, Cherrington A, Richman J, Scarinci IC, Houston TK. Disparities in self-monitoring of blood glucose among low-income ethnic minority populations with diabetes, United States. Ethnicity & disease. 2009 Jan 1; 19(2):97-103. [view]
5. Yu FB, Menachemi N, Berner ES, Allison JJ, Weissman NW, Houston TK. Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospitals. American journal of medical quality : the official journal of the American College of Medical Quality. 2009 Jul 1; 24(4):278-86. [view]
6. Levine DA, Funkhouser EM, Houston TK, Gerald JK, Johnson-Roe N, Allison JJ, Richman J, Kiefe CI. Improving care after myocardial infarction using a 2-year internet-delivered intervention: the Department of Veterans Affairs myocardial infarction-plus cluster-randomized trial. Archives of internal medicine. 2011 Nov 28; 171(21):1910-7. [view]
7. Houston TK, Richman JS, Ray MN, Allison JJ, Gilbert GH, Shewchuk RM, Kohler CL, Kiefe CI, DPBRN Collaborative Group. Internet delivered support for tobacco control in dental practice: randomized controlled trial. Journal of Medical Internet Research [Electronic Resource]. 2008 Nov 4; 10(5):e38. [view]
8. Houston TK, Funkhouser E, Allison JJ, Levine DA, Williams OD, Kiefe CI. Multiple measures of provider participation in Internet delivered interventions. Studies in health technology and informatics. 2007 Jan 1; 129(Pt 2):1401-5. [view]
9. Funkhouser E, Houston TK, Levine DA, Richman J, Allison JJ, Kiefe CI. Physician and patient influences on provider performance: ß-blockers in postmyocardial infarction management in the MI-Plus study. Circulation. Cardiovascular quality and outcomes. 2011 Jan 1; 4(1):99-106. [view]
10. Ahern DK, Woods SS, Lightowler MC, Finley SW, Houston TK. Promise of and potential for patient-facing technologies to enable meaningful use. American journal of preventive medicine. 2011 May 1; 40(5 Suppl 2):S162-72. [view]
11. Jamerson KA, Basile J. Prompt, aggressive BP lowering in high-risk patients. Journal of clinical hypertension (Greenwich, Conn.). 2008 Jan 1; 10(1 Suppl 1):40-8. [view]
12. Funkhouser E, Levine DA, Gerald JK, Houston TK, Johnson NK, Allison JJ, Kiefe CI. Recruitment activities for a nationwide, population-based, group-randomized trial: the VA MI-Plus study. Implementation science : IS. 2011 Sep 9; 6(1):105. [view]
13. Basile J. Shifting paradigms in defining and treating hypertension: addressing global risk with combination therapy. Journal of clinical hypertension (Greenwich, Conn.). 2008 Jan 1; 10(1 Suppl 1):2-3. [view]
14. Basile J. The importance of prompt blood pressure control. Journal of clinical hypertension (Greenwich, Conn.). 2008 Jan 1; 10(1 Suppl 1):13-9. [view]
15. Miller MJ, Allison JJ, Schmitt MR, Ray MN, Funkhouser EM, Cobaugh DJ, Saag KG, LaCivita C. Using single-item health literacy screening questions to identify patients who read written nonsteroidal anti-inflammatory medicine information provided at pharmacies. Journal of Health Communication. 2010 Jun 1; 15(4):413-27. [view]

Conference Presentations

1. Funkhouser E. A Group Randomized Trail of an Internet-Delivered Intervention Improved Lipid and Diabetes Control in Veterans with Myocardial Infarction: VA MI-Plus. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD. [view]
2. Salanitro AH, Agee B, Burczyk-Brown JJ, Crenshaw K, Horton T, Kaffka JS, Funkhouser E, Halanych JH, Muntner P, Richman JS, Safford MM. Appropriate inaction and 'clinical inertia'. Paper presented at: Society of General Internal Medicine Midwest Regional Annual Meeting; 2010 Apr 29; Minneapolis, MN. [view]
3. Tipton EF. Participation of VA Versus Non-VA Providers in the MI+ Study. Paper presented at: VA Birmingham VAMC Annual Research Week; 2006 Mar 12; Birmingham, AL. [view]
4. Tipton EF. What Determines Efficiency of Site Recruitment in a Large Multi-site VA Study? Paper presented at: VA Birmingham VAMC Annual Research Week; 2006 Mar 4; Birmingham, AL. [view]

DRA: Health Systems Science
DRE: none
Keywords: Behavior (provider)
MeSH Terms: Focus Groups, Myocardial Infarction, Guidelines, Comorbidity, Health Education, Physician Practice Patterns