Using Data-Driven Implementation Strategies to Improve the Quality of Cirrhosis Care

使用数据驱动的实施策略提高肝硬化护理质量

• 批准号: 10178108
• 负责人: Shari S Rogal
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-10-01 至 2022-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10178108
• 关键词: Action Research; Address; Adherence; Administrator; Adoption; Adult; Affect; Alcohols; Caring; Cause of Death; Cirrhosis; Cluster randomized trial; Collaborations; Country; Data; Effectiveness; Esophageal Varix; Evaluation; Evidence based practice; Excess Mortality; Fatty Liver; Future; Goals; Guidelines; HIV; Health; Health Services; Healthcare; Hemorrhage; Hepatic; Hepatitis; Hepatitis C; Hepatitis C Therapy; Hospitalization; Hospitals; Hybrids; Infrastructure; Intervention; Interview; Learning; Life; Link; Liver diseases; Maintenance; Measurement; Measures; Methods; Mission; Monitor; Outcome; Patient-Focused Outcomes; Patients; Performance; Prevalence; Primary carcinoma of the liver cells; Process; Promoting Action on Research Implementation in Health Services framework; Provider; Quality of Care; Recommendation; Research Personnel; Resources; Savings; Scientist; Screening for Hepatocellular Cancer; Services; Site; Specific qualifier value; Structure; Surveys; Techniques; Testing; Time; Translating; Use Effectiveness; Varicosity; Veins; Veterans; Veterans Health Administration; Work; aged; base; behavioral health; clinical practice; comparative; design; disability; effectiveness evaluation; evidence based guidelines; follow-up; high risk; implementation intervention; implementation measures; implementation science; implementation strategy; improved; innovation; intervention mapping; member; middle age; military veteran; multidisciplinary; operation; prevent; primary outcome; programs; response; screening; successful intervention; tool; uptake

Cirrhosis, or advanced liver disease, is the 4th leading and fastest-growing cause of death in the US among those aged 45-64 and ranks among the top three leading causes of excess mortality in the US overall. Nearly 120,000 Veterans under the care of the Veterans Healthcare Administration (VHA) have cirrhosis due to alcohol, hepatitis C, fatty liver disease, or other causes, and this number is rapidly increasing. There are life- saving measures that providers can take to prevent harm from cirrhosis, including providing access to post- discharge follow-up care and screening for liver cancer and esophageal varices (veins that can cause catastrophic bleeding). However, less than 30% of Veterans receive care concordant with these three evidence-based practices (EBPs). Therefore, our operations partner, the HIV, Hepatitis, and Related Conditions Program Office (HHRC) created a learning collaborative to improve the uptake of cirrhosis EBPs in VA. As the evaluation team for this Hepatic Innovation Team (HIT) Collaborative, we have developed this Partnered Evaluation Initiative at the request of and in collaboration with HHRC. Through this PEI we aim to understand which implementation strategies, or discrete activities that are conducted to promote EBP implementation, can help improve the uptake of EBPs for cirrhosis care. Our specific aims are to: 1) Empirically determine which combinations of implementation strategies are associated with the successful implementation of EBPs for Veterans with cirrhosis; 2) Use Intervention Mapping to operationalize these ‘data-driven’ implementation strategies; and 3) Assess the effectiveness of using data-driven implementation strategies to increase cirrhosis EBP uptake in a hybrid type III stepped wedge cluster randomized trial. To accomplish these aims we have adapted a survey of 73 implementation strategies, as defined by implementation science experts, that we successfully used in hepatitis C quality improvement efforts, with response rates of up to 84% nationally across 130 VA stations. We will administer this survey to all VA stations and use traditional statistical and configurational comparative methods to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. We will then use Intervention Mapping, a systematic, stakeholder-driven, six-step process for developing interventions and implementation strategies, to develop these strategies into a manualized, facilitated intervention, guided by the integrated-Promoting Action Research on Implementation in Health Services (i-PARIHS) framework. We will then test this implementation strategy bundle in 12 sites with low adherence to EBPs for Veterans with cirrhosis using a stepped wedge design in which four sites will cross from control to intervention approximately every 6 months. We will assess the impact of the implementation intervention on the primary outcome of patient level guideline-concordant care and on multiple measures of implementation (e.g., adoption, maintenance). Our work is at the request of our partner HHRC, and we have also partnered with investigators from the following centers and QUERIs: The National Hepatic Consortium for Redesigning Care (NCRC), BridgeQUERI, the QUERI for Team-Based Behavioral Health, Precision Monitoring to Transform Care (PRIS-M) QUERI, and the Office of Healthcare Transformation (OHT). This project is a natural extension of our prior work and aligns with HSR&D’s priorities regarding advancing implementation science and measurement methods, ORD’s priority to increase the real-world impact of VA work, and VA’s overarching goals to (1) focus resources more efficiently (by guiding sites towards effective and efficient practices) and (2) improve the quality and timeliness of services. Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform implementation interventions for low-performing sites, thus providing quality improvement tools that will allow VA to enhance the effectiveness and efficiency of national programming more broadly.

肝硬化或晚期肝病是美国第四大且增长最快的死因 45-64岁人群是美国总体死亡率过高的三大主要原因之一。几乎 退伍军人医疗保健管理局 (VHA) 照顾的 120,000 名退伍军人因以下原因患有肝硬化： 酒精、丙型肝炎、脂肪肝或其他原因，而且这个数字正在迅速增加。还有生命—— 提供者可以采取的预防肝硬化危害的节约措施，包括提供术后恢复的机会 出院后续护理和肝癌和食管静脉曲张（可导致静脉曲张）的筛查 灾难性的出血）。然而，只有不到 30% 的退伍军人接受与这三项相一致的护理 基于证据的实践（EBP）。因此，我们的运营合作伙伴，艾滋病毒、肝炎及相关疾病 条件计划办公室 (HHRC) 创建了一个学习合作组织，以提高肝硬化 EBP 的吸收率 弗吉尼亚州。作为本次肝脏创新团队 (HIT) 合作的评估团队，我们开发了此 应 HHRC 的要求并与 HHRC 合作开展合作评估计划。通过这个 PEI，我们的目标是 了解为促进 EBP 所采取的实施策略或离散活动 实施，可以帮助提高 EBP 在肝硬化护理中的吸收。我们的具体目标是：1) 根据经验确定哪些实施策略组合与 为患有肝硬化的退伍军人成功实施 EBP； 2) 使用干预映射 实施这些“数据驱动”的实施策略； 3) 评估使用的有效性 数据驱动的实施策略，以混合 III 型步骤增加肝硬化 EBP 的摄取 楔形聚类随机试验。为了实现这些目标，我们对 73 个实施情况进行了调查 由实施科学专家定义的策略，我们成功用于丙型肝炎质量 改进工作，全国 130 个 VA 站点的响应率高达 84%。我们将管理 这项调查对所有 VA 站进行，并使用传统的统计和配置比较方法 确定哪些实施策略组合与站点级 EBP 遵守相关 对于肝硬化。然后，我们将使用干预映射，这是一个系统的、利益相关者驱动的、六步流程 制定干预措施和实施策略，将这些策略发展为手动的、 在卫生领域实施综合促进行动研究的指导下促进干预 服务 (i-PARIHS) 框架。然后，我们将在 12 个低网络站点测试此实施策略包。 使用阶梯式楔形设计，使患有肝硬化的退伍军人遵守 EBP，其中四个站点将从 大约每 6 个月控制一次干预。我们将评估实施的影响 对患者水平指南一致护理的主要结局以及多种措施进行干预 实施（例如采用、维护）。我们的工作是应我们的合作伙伴 HHRC 的要求进行的，我们有 还与以下中心和 QUERI 的研究人员合作： 国家肝脏联盟 重新设计护理 (NCRC)、BridgeQUERI、基于团队的行为健康、精准监测的 QUERI 医疗改革转型 (PRIS-M) QUERI 和医疗保健转型办公室 (OHT)。这个项目是一个 我们之前工作的自然延伸，并与 HSR&D 关于推进实施的优先事项保持一致 科学和测量方法，ORD 优先考虑增加 VA 工作的现实世界影响，以及 VA 总体目标是 (1) 更有效地集中资源（通过指导网站走向有效和高效的方向） (2) 提高服务质量和及时性。此次创新成果的顺利完成 评价将确定使用早期评价数据为实施干预措施提供信息的可行性 低绩效网站，从而提供质量改进工具，使 VA 能够提高效率 以及更广泛的国家规划的效率。

项目成果

Core implementation strategies for improving cirrhosis care in the Veterans Health Administration.

• DOI: 10.1002/hep.32395
• 发表时间: 2022-08
• 期刊: HEPATOLOGY
• 影响因子: 13.5
• 作者: Yakovchenko, Vera;Morgan, Timothy R.;Miech, Edward J.;Neely, Brittney;Lamorte, Carolyn;Gibson, Sandra;Beste, Lauren A.;McCurdy, Heather;Scott, Dawn;Gonzalez, Rachel, I;Park, Angela M.;Powell, Byron J.;Bajaj, Jasmohan S.;Dominitz, Jason A.;Chartier, Maggie;Ross, David B.;Chinman, Matthew J.;Rogal, Shari S.
• 通讯作者: Rogal, Shari S.