The application for the funding of this $50,000, 6-month planning project was submitted in response to VA HSR&D Service’s call for collaborative studies between health services researchers and VA network(s) focusing on the implementation and evaluation of an evidence-based clinical intervention. Our project focused on the implementation of the results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). ALLHAT, the results of which appeared in press in 12/02, showed that thiazide-based antihypertensive regimens are superior in terms of cost-effectiveness to other regimens. ALLHAT is the largest randomized trial ever conducted to examine the effects of antihypertensive drugs on clinical outcomes. Despite the indubitable applicability and usefulness of ALLHAT’s findings to VA and non-VA patients and providers, implementation of ALLHAT findings into routine VA or non-VA clinical practice has been insubstantial.
Our goal was to develop and test a simple, explainable, and exportable implementation model for the ALLHAT findings using the General Medicine Primary Care Practice at the Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston as the test bed. Our long-term goal was to develop an implementation model suitable for use within ever larger circles at the MEDVAMC, VISN 16, and VA-wide. Specific objectives were: (1) to facilitate the implementation into routine clinical practice of the major findings of ALLHAT, namely that thiazide-based antihypertensive regimens are the treatment of choice for the majority of patients with hypertension, and (2) to generate knowledge that will facilitate implementation of ALLHAT through a) activities based on the principles of diffusion science described by Everett Rogers and b) through the development of an ALLHAT implementation plan that incorporates critical general as well the context- or site-specific implementation lessons and strategies.
In keeping with the nature of a “planning project,” several key design features of the implementation intervention were set down before the project started, while others were allowed to emerge as the project teams did their work. There were four key a priori design features. First, the implementation plan was based on the “Diffusion of Innovations Model” of Everett Rogers. Second, the communicators of the innovation, who were also the proposers of the entire project, were the members of the MEDVAMC General Medicine Section (GMS). The GMS is a unique group of individuals who understand the complex and multiple realities of the VA system because within this system they care for patients, educate internal medicine trainees, and conduct health services research. Third, the GMS and the roughly 6,000 patients they care for constitute what the Institute of Medicine (IOM) calls a microsystem of care, all of whom have a stake in the improvement of GMS quality of care. Fourth, the implementation plan was team-based, with the GMS member working on teams aligned with the Rogers diffusion model. These four teams devised tangible products (e.g., pocket medication algorithm cards), planned and carried out functions (e.g., analysis of prescribing patterns), and served as ALLHAT messengers with key parties (e.g. patients, Pharmacy & Therapeutics Committee).
Preliminary results show that the multifaceted implementation intervention led to an increase in the proportion of GM hypertensive patients who were being treated with a thiazide based antihypertensive regimen. This increase was not seen in the larger group of PrimeCare hypertensives, whose providers were not participating in this planning project because we a) needed time to develop the implementation model and b) needed them to serve as concurrent controls.
Many facilitators and barriers to implementation were uncovered.
Full scale implementation of thiazide-based antihypertensive regimens as the treatment of choice could significantly improve veterans’ health outcomes and could result in considerable cost savings for the VA medical care system.
None at this time.
Treatment - Observational
Hypertension, Implementation, Primary care