scholarly journals Increasing enrolment in a national VA transitions of care programme: a pre–post evaluation of a data dashboard and nudge-based intervention

2021 ◽  
Vol 28 (1) ◽  
pp. e100416
Author(s):  
Brigid Connelly ◽  
Chelsea Leonard ◽  
David Gaskin ◽  
Theodore Warsavage ◽  
Heather Gilmartin
Keyword(s):  
Performance Metrics ◽  
Transitions Of Care ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Care Programme ◽  
Post Evaluation ◽  
The Difference ◽  
Two Phases ◽  
One Year

BackgroundThe rural transitions nurse programme (TNP) is a care coordination intervention for high-risk veterans. An interactive dashboard was used to provide real-time performance metrics to sites as an audit and feedback tool. One-year post implementation, enrolment goals were not met. Nudge emails were introduced to increase TNP veteran enrolment. This study evaluated whether veteran enrolment increased when feedback occurred through a dashboard plus weekly nudge email versus dashboard alone.Setting/populationThis observational study included veterans who were hospitalised and discharged from four Veterans Health Administration hospitals participating in TNP.MethodsVeteran enrolment counts between the dashboard phase and dashboard plus weekly nudge email phase were compared. Nudge emails included run charts of enrolment data. The difference of means for weekly enrolment between the two phases were calculated. After 3 months of nudge emails, a survey assessing TNP transitions nurse and physician champion perceptions of the nudge emails was distributed.ResultsThe average enrolment for the four TNP sites during the ~20-month dashboard only phase was 4.23 veterans/week. The average during the 3-month dashboard plus nudge email phase was 4.21 veterans/week. The difference in means was −0.03 (p=0.73). Adjusting for time trends had no further effect. Four nurses responded to the survey. Two nurses reported neutral and two reported positive perceptions of the nudge emails.ConclusionDrawing attention to metrics, through nudge emails, maintained, but did not increase TNP veteran discharges compared to dashboard feedback alone.

Results of a Regional Effort to Improve Warfarin Management

2016 ◽  
Vol 51 (5) ◽  
pp. 373-379 ◽  
Author(s):  
Adam J. Rose ◽  
Angela Park ◽  
Christopher Gillespie ◽  
Carol Van Deusen Lukas ◽  
Al Ozonoff ◽  
...  
Keyword(s):  
Quality Improvement ◽  
New England ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Veterans Health ◽  
Health Administration ◽  
Process Of Care ◽  
Processes Of Care ◽  
Anticoagulation Control

Background: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. Objective: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). Methods: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. Results: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. Conclusions: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

scholarly journals The LEAP Program: Quality Improvement Training to Address Team Readiness Gaps Identified by Implementation Science Findings

2020 ◽  
Author(s):  
Laura J. Damschroder ◽  
Nicholas R. Yankey ◽  
Claire H. Robinson ◽  
Michelle B. Freitag ◽  
Jennifer A. Burns ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Training Program ◽  
Learning Community ◽  
Organizational Readiness ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Program Satisfaction ◽  
Implementing Change ◽  
Assignment Completion

Abstract Background Integrating evidence-based innovations (EBIs) into sustained use is challenging; most implementations in health systems fail. Increasing frontline teams’ quality improvement (QI) capability may increase the implementation readiness and success of EBI implementation. Objectives Develop a QI training program (“Learn. Engage. Act. Process.” (LEAP)) and evaluate its impact on frontline obesity treatment teams to improve treatment delivered within the Veterans Health Administration (VHA). Design This was a pre-post evaluation of the LEAP program. MOVE! coordinators (N = 68) were invited to participate in LEAP; 24 were randomly assigned to four starting times. MOVE! coordinators formed teams to work on improvement aims. Pre-post surveys assessed team organizational readiness for implementing change and self-rated QI skills. Program satisfaction, assignment completion, and aim achievement were also evaluated. Participants VHA facility-based MOVE! teams. Interventions LEAP is a 21-week QI training program. Core components include audit and feedback reports, structured curriculum, coaching and learning community, and online platform. Main Measures Organizational readiness for implementing change (ORIC); self-rated QI skills before and after LEAP; assignment completion and aim achievement; program satisfaction. Key Results Seventeen of 24 randomized teams participated in LEAP. Participants' self-ratings across six categories of QI skills increased after completing LEAP (p< 0.0001). The ORIC measure showed no statistically significant change overall; the change efficacy subscale marginally improved (p < 0.08), and the change commitment subscale remained the same (p = 0.66). Depending on the assignment, 35 to 100% of teams completed the assignment. Nine teams achieved their aim. Most team members were satisfied or very satisfied (81–89%) with the LEAP components, 74% intended to continue using QI methods, and 81% planned to continue improvement work. Conclusions LEAP is scalable and does not require travel or time away from clinical responsibilities. While QI skills improved among participating teams and most completed the work, they struggled to do so amid competing clinical priorities.

scholarly journals Protocol: A Multi-Modal, Physician-Centered Intervention to Improve Guideline-Concordant Prostate Cancer Imaging

2020 ◽  
Author(s):  
Danil V Makarov ◽  
Shannon Ciprut ◽  
Matthew Kelly ◽  
Dawn Walter ◽  
Michele G Shedlin ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Data Collection ◽  
Behavior Change ◽  
Cancer Imaging ◽  
Intervention Strategy ◽  
Theoretical Domains Framework ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Multi Level

Abstract Background: Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that 1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment, 2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer.Methods: We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: 1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers’ and to published guidelines 2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and 3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically-distributed study sites.Discussion: This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed.Trial Registration: This study was prospectively registered on February 26, 2018, CliniclTrials.gov: NCT03445559 (2a)

Deriving Weight from Big Data: A Comparison of Body Weight Measurement Cleaning Algorithms (Preprint)

2021 ◽  
Author(s):  
Richard Evans ◽  
Jennifer Burns ◽  
Anne Annis ◽  
Michelle Freitag ◽  
Susan Raffa ◽  
...  
Keyword(s):  
Body Weight ◽  
Veterans Health Administration ◽  
Primary Care Visit ◽  
Veterans Health ◽  
Health Administration ◽  
Weight Measurement ◽  
Care Visit ◽  
Complex Models ◽  
One Year ◽  
Weight Data

BACKGROUND Patient body weight is a frequently utilized measure in biomedical studies, yet there are exist no standard methods for processing and cleaning weight data. Conflicting documentation on constructing body weight measurements presents challenges for research and program evaluation. OBJECTIVE We sought to describe and compare methods for extracting and cleaning weight data from electronic health record (EHR) databases to develop guidelines for standardized approaches that promote reproducibility. METHODS We conducted a systematic review of studies that used Veterans Health Administration (VHA) EHR weight data, published from 2008 – 2018 and documented the algorithms for constructing patient weight. We applied these algorithms to a cohort of veterans with at least one Primary Care visit in 2016. The resulting weight measures were compared at the patient and site levels. RESULTS We identified 496 studies and included 62 that utilized weight as outcome variables; 48% included a replicable algorithm. Algorithms varied from cut-offs of implausible weights to complex models using measures within patient over time. We found differences in the number of weight values after applying the algorithms (86% to 99% of raw data) and decreased variance (SD = 68 to 54), but little difference in average weights across methods (216 to 220 lbs.). The percent of patients with at least 5% weight loss over one year ranged from 18% to 24%. CONCLUSIONS Determining the best method to assess weight using EHR data can be computationally demanding. Our results suggest that for many studies, applying simple cut-offs that require fewer computing resources and are easier to understand may be sufficient. We present guidelines for situations where more complex approaches may be warranted.

Multi-tiered External Facilitation: The Role of Feedback Loops and Tailored Interventions in Supporting Change in a Stepped-Wedge Implementation Trial

2020 ◽  
Author(s):  
Lauren S Penney ◽  
Teresa M. Damush ◽  
Nicholas A. Rattray ◽  
Edward J. Miech ◽  
Sean A. Baird ◽  
...  
Keyword(s):  
Feedback Loops ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Or Education ◽  
Implementation Support ◽  
Local Contexts ◽  
Support Team ◽  
Time Periods ◽  
External Facilitation

Abstract Background Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. The contextual factors that prompt facilitators to tailor activities have not been well-described. Methods We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed, perceived, and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (n=78), and collaborative call debriefs (n=22). Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. Results Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse, and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. Conclusions Multi-tiered facilitation capitalizing on feedback loops allowed for tailored, site-directed facilitation that aligned with the types of supports that local participants valued. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress.

scholarly journals Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging

2020 ◽  
Author(s):  
Danil V Makarov ◽  
Shannon Ciprut ◽  
Matthew Kelly ◽  
Dawn Walter ◽  
Michele G Shedlin ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Data Collection ◽  
Behavior Change ◽  
Cancer Imaging ◽  
Intervention Strategy ◽  
Theoretical Domains Framework ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Multi Level

Abstract Background Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that 1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment, 2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer. Methods We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: 1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers’ and to published guidelines 2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and 3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically-distributed study sites. Discussion This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed.

Nutritional status and outcomes of veterans undergoing curative surgery for colorectal cancer.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18585-e18585
Author(s):  
Urvashi Mitbander ◽  
Timothy Frankel ◽  
Irina Y. Dobrosotskaya
Keyword(s):  
Colorectal Cancer ◽  
Weight Loss ◽  
Tertiary Care ◽  
Veterans Health ◽  
Health Administration ◽  
Significant Weight Loss ◽  
Curative Surgery ◽  
Curative Intent ◽  
Post Surgery ◽  
One Year

e18585 Background: Malnutrition is highly prevalent within the cancer population. Malnourishment has various negative surgical and oncologic impacts. The Veterans Health Administration (VHA) provides comprehensive care to patients in a single-payer system allowing for capture of peri-operative data and the opportunity for focused pre-operative (pre-op) interventions to improve outcomes. We sought to study the effect of pre-op weight and albumin on post-operative (post-op) complications in a contemporaneous group of veterans with colorectal cancer (CRC) at a tertiary care Veterans Affairs (VA) hospital. Methods: This is a retrospective review of 105 patients with colorectal malignancies treated with curative intent surgery at the VA Ann Arbor Healthcare System between January 2015 and January 2020. Patients with distant metastatic disease, neoadjuvant therapy, non-adenocarcinoma histology, or those receiving majority of care outside of the VHA were excluded. We examined BMI trends from one year prior to one year post surgery, rates of nutrition consults, and post-op complications defined as abnormal clinical developments such as, but not limited to, infection and delayed wound healing. Fisher’s exact test was used for analysis. Results: At time of CRC diagnosis, the mean age was 70.3 ± 9.1 and the median stage was T2N0. Surgical resections were 65% (n = 68) laparoscopic. Pre-op weight loss from 6 months prior to diagnosis to time of surgery was observed in the majority of patients (n = 47, 64%). Significant weight loss, defined as ≥3% weight reduction, was seen in 45% (n = 33) of patients. A quarter of patients were identified to have a low pre-op albumin of less than 3.5 (n = 25, 25%). Significant weight loss and low pre-op albumin were each independently associated with increased post-op complications (p < 0.01). Post-op weight loss was seen in 81% (n = 73) and 69% (n = 48) of patients at 30- and 60-days post-op, respectively, and was not associated with post-op complications. Inpatient post-op nutrition consultation was performed in 96% (n = 101) of patients; nutritional supplements were recommended in only 23% (n = 23) of cases. In patients with significant weight loss, pre-op nutrition evaluation was performed in 15% (n = 5) of cases and post-op outpatient nutrition follow up occurred in 18% (n = 6) of cases. Conclusions: 45% of patients had ≥3% weight loss 6 months prior to diagnosis of CRC and 25% of patients had low albumin levels. These led to greater post-operative complications. An intensive nutrition pre-habilitation program to address weight loss and low albumin prior to surgery for CRC is needed and may reduce associated complications.

scholarly journals Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration

Neurology ◽  
2017 ◽  
Vol 89 (24) ◽  
pp. 2422-2430 ◽  
Author(s):  
Teresa M. Damush ◽  
Edward J. Miech ◽  
Jason J. Sico ◽  
Michael S. Phipps ◽  
Greg Arling ◽  
...  
Keyword(s):  
Care Facility ◽  
Clinical Staff ◽  
Barriers And Facilitators ◽  
Audit And Feedback ◽  
System Level ◽  
Evidence Based ◽  
Veterans Health ◽  
Health Administration ◽  
Cross Sectional

Objective:To identify key barriers and facilitators to the delivery of guideline-based care of patients with TIA in the national Veterans Health Administration (VHA).Methods:We conducted a cross-sectional, observational study of 70 audiotaped interviews of multidisciplinary clinical staff involved in TIA care at 14 VHA hospitals. We de-identified and analyzed all transcribed interviews. We identified emergent themes and patterns of barriers to providing TIA care and of facilitators applied to overcome these barriers.Results:Identified barriers to providing timely acute and follow-up TIA care included difficulties accessing brain imaging, a constantly rotating pool of housestaff, lack of care coordination, resource constraints, and inadequate staff education. Key informants revealed that both stroke nurse coordinators and system-level factors facilitated the provision of TIA care. Few facilities had specific TIA protocols. However, stroke nurse coordinators often expanded upon their role to include TIA. They facilitated TIA care by (1) coordinating patient care across services, communicating across service lines, and educating clinical staff about facility policies and evidence-based practices; (2) tracking individual patients from emergency departments to inpatient settings and to discharge for timely follow-up care; (3) providing and referring TIA patients to risk factor management programs; and (4) performing regular audit and feedback of quality performance data. System-level facilitators included clinical service leadership engagement and use of electronic tools for continuous care across services.Conclusions:The local organization within a health care facility may be targeted to cultivate internal facilitators and a systemic infrastructure to provide evidence-based TIA care.

scholarly journals Hematocrit levels and thrombotic events in patients with polycythemia vera: an analysis of Veterans Health Administration data

2019 ◽  
Vol 98 (11) ◽  
pp. 2533-2539
Author(s):  
Shreekant Parasuraman ◽  
Jingbo Yu ◽  
Dilan Paranagama ◽  
Sulena Shrestha ◽  
Li Wang ◽  
...  
Keyword(s):  
Polycythemia Vera ◽  
Cox Regression ◽  
Veterans Health Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Monitoring And Control ◽  
The Difference ◽  
And Control ◽  
The Relationship

Abstract Patients with polycythemia vera (PV) have a high incidence of thrombotic events (TEs), contributing to a greater mortality risk than the general population. The relationship between hematocrit (HCT) levels and TE occurrence among patients with PV from the Veterans Health Administration (VHA) was evaluated to replicate findings of the CYTO-PV trial with a real-world patient population. This retrospective study used VHA medical record and claims data from the first claim with a PV diagnosis (index) until death, disenrollment, or end of study, collected between October 1, 2005, and September 30, 2012. Patients were aged ≥ 18 years at index, had ≥ 2 claims for PV (ICD-9-CM code, 238.4) ≥ 30 days apart during the identification period, continuous health plan enrollment from 12 months pre-index until end of study, and ≥ 3 HCT measurements per year during follow-up. This analysis focused on patients with no pre-index TE, and with all HCT values either < 45% or ≥ 45% during the follow-up period. The difference in TE risk between HCT groups was assessed using unadjusted Cox regression models based on time to first TE. Patients (N = 213) were mean (SD) age 68.9 (11.5) years, 98.6% male, and 61.5% white. TE rates for patients with HCT values < 45% versus ≥ 45% were 40.3% and 54.2%, respectively. Among patients with ≥ 1 HCT before TE, TE risk hazard ratio was 1.61 (95% CI, 1.03–2.51; P = 0.036). This analysis of the VHA population further supports effective monitoring and control of HCT levels < 45% to reduce TE risk in patients with PV.

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