We postulate that the creation of a system change designed to respond to new clinical knowledge (JNC7 guidelines) yields timely and patient centered changes in care. A systems-based approach to the complex problems associated with the changing evidence regarding medications can help to eliminate delays in patient care and disseminate new clinical knowledge in an effective manner. However, a common challenge to healthcare systems is development of strategies that inform and educate rather than enforce medical decisions (1). Telling the provider what to do is unlikely to achieve learning or improve the quality of care provided to the patient. Successful strategies for changing physician behavior reduce complexity for the provider and optimize information processing. In order to integrate knowledge into practice the practitioner must move from awareness of the new guidelines to agreement, adoption and adherence with new clinical information.
Our aim is to develop a paradigm for change based on Kassirer’s informing and educating model and knowledge translation theory and then bring about change using the paradigm and information technology to implement evidence-based practice. Knowledge translation, popularized by the Canadian Institutes of Health Research, involves translation of new information into knowledge for users; it moves beyond reliance on publication as a mechanism for disseminating results. The dynamic mechanisms of knowledge translation have been shown to increase uptake and application of research information. In our center, we have been applying knowledge translation to inform patients and providers of new information regarding changes in effective drug treatment. We recently conducted a study of practice change involving hormone replace therapy. We propose that our paradigm involving the pharmacy, patient and physician will be an effective way to influence a change to clinician inertia.
The second aim is to build an infrastructure and relationship between the VISN and Facility performance measurement and quality offices to leverage existing assets and resources in the spread of quality improvement for implementing evidence based practice. The paradigm for this relationship will move from one that “supports” quality improvement to one that becomes involved and actively “enables” quality improvement. An infrastructure and relationship between VISN and Facility quality improvement is instrumental to VISN-wide implementation, maintenance and spread of evidence-based practice.
During the six-month planning project, we will refine our Knowledge Translation paradigm by conducting debriefing on groups of VA patients and providers who participated in our earlier study, visit and hold teleconferences with key stakeholders across the VISN, conduct a pilot study on the use of diuretics for uncomplicated hypertension (IRB #031096), and identify a candidate portfolio of evidence-based clinical practices of drug treatment through a literature search and an advisory committee. We will also develop a collaborative relationship between VISN and Facility leadership in quality improvement based on “enabling” rather than merely “supporting” quality improvement (the Collaborative). The planning project will culminate in a Final Proposal for an organizational approach for implementing evidence-based clinical practices.
Planning pilot study: Providers were randomized into three intervention arms: 1) physician education of hypertension guidelines, 2) physician education plus pharmacy alerts placed in patient electronic medical record, 3) physician education, pharmacy alert plus letter to the patient from the pharmacy regarding hypertension education.
There were 205 providers with 1,847 patients on a single HTN medication with uncontrolled hypertension at the pilot site. 496 patients involving 23 providers were excluded because they either were actually on more than HTN medication or they participation. The provider education group included 326 patients and 54 providers; the pharmacy alert group included 552 patients and 62 providers; and the patient education group included 473 patients and 66 providers. 1,025 pharmacy alerts were received by 128 providers. 38.8% of the providers responded to the alert within two weeks; half of these responses involved treatment changes and half were negative responses.
We conducted a qualitative study to evaluate negative provider responses with regard to sub-optimal hypertension care using the Cabana framework of barriers to implementation of guidelines. Clinical inertia accounted for 65% of these negative responses. This paper is currently being written.
Site visits by the investigators are ongoing for building the Collaborate infrastructure. We have recruited site principal investigators and have submitted IRB applications at two additional medical centers within the VISN. The Collaborative will report to a new VISN level subcommittee on care delivery chaired by Dr. Alvarez, VISN medical director and co-principal investigator.
One of the Strategic Objectives of VISN 9 is “Put Quality First Until First in Quality” and the measure that has been set as a marker of quality is the improved performance in the care of chronic diseases, such as hypertension. By creating a system change in the delivery of the healthcare to patients with chronic disease (e.g., hypertension), we can help providers overcome clinical inertia and draw attention to services potentially deviating from guidelines of care (e.g., a patient’s blood pressure that may not be controlled). This would address the Institute of Medicine’s domains of quality and help achieve the VISN’s strategic objectives. This can be realized through optimizing the effectiveness of care provided to veterans and through a focus on patient centered care. We can use this occasion to create opportunities for education of both the patients and providers.
Through the study of provider behaviors, we can begin to understand and employ approaches to the systematic application of evidence based practice guidelines in order to improve the quality of the healthcare provided to patients by minimizing the variation that exists in outpatient settings for the three largest resource utilizing chronic diseases, hypertension, diabetes, and hyperlipidemia.
- Roumie CL, Elasy TA, Greevy R, Griffin MR, Liu X, Stone WJ, Wallston KA, Dittus RS, Alvarez V, Cobb J, Speroff T. Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. Annals of internal medicine. 2006 Aug 1; 145(3):165-75.
- Roumie CL, Elasy TA, Greevy R, Griffin MR, Liu X, Stone WJ, Wallston KA, Dittus RS, Alvarez V, Cobb J, Speroff T. Patient education adds critical boost to hypertension management. [Editorial]. VA Research Currents. 2006 Sep 1; 7-8.