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

肝硬化或晚期肝病是美国第四大和增长最快的死亡原因， 年龄在45-64岁之间的人，并且是美国总体死亡率过高的三大主要原因之一。近 在退伍军人医疗保健管理局（VHA）的照顾下，120，000名退伍军人因肝硬化而患有肝硬化。 酒精，丙型肝炎，脂肪肝或其他原因，这个数字正在迅速增加。有生命- 提供者可以采取的预防肝硬化损害的措施，包括提供术后 出院后的随访护理和肝癌和食管静脉曲张的筛查（可能导致 灾难性出血）。然而，只有不到30%的退伍军人得到与这三个方面一致的照顾。 循证实践（EBP）。因此，我们的业务合作伙伴，艾滋病毒，肝炎和相关疾病 条件计划办公室（HHRC）创建了一个学习协作，以提高肝硬化EBP的吸收， 弗吉尼亚作为该肝脏创新团队（HIT）协作的评估团队，我们开发了 应人权事务委员会的请求并与其合作开展合作评估倡议。通过这个PEI，我们的目标是 了解为促进EBP而实施的实施策略或离散活动 实施，可以帮助提高肝硬化护理的EBP的吸收。我们的具体目标是：1） 根据经验确定实施策略的哪些组合与 成功实施EBP的退伍军人与肝硬化; 2）使用干预映射， 实施这些“数据驱动”的实施战略;以及3）评估使用 数据驱动的实施策略，以增加肝硬化EBP摄取的混合III型步进 楔形群随机试验。为了实现这些目标，我们对73项实施情况进行了调查， 由实施科学专家定义的策略，我们成功地用于丙型肝炎质量 改进工作，全国130个VA站的响应率高达84%。我们将管理 这项调查的所有VA站，并使用传统的统计和配置比较方法， 确定实施策略的哪些组合与站点级遵守EBP相关 治疗肝硬化然后，我们将使用干预映射，这是一个系统的、由股东驱动的六步过程， 制定干预措施和实施战略，将这些战略发展成为一个手册， 促进干预，以综合促进健康实施行动研究为指导， （i）PARIHS框架。然后，我们将在12个站点测试此实施策略包， 坚持EBP的退伍军人与肝硬化使用阶梯楔形设计，其中四个网站将交叉， 大约每6个月进行一次干预。我们将评估实施的影响 对患者水平指南一致性护理的主要结局和多项措施的干预 实现（例如，收养、抚养）。我们的工作是应我们的合作伙伴人权委员会的要求， 还与来自以下中心和QUERI的研究者合作： 重新设计护理（NCRC），BridgeQUERI，基于团队的行为健康QUERI，精确监测 转换护理（PRIS-M）QUERI和医疗保健转型办公室（OHT）。这个项目是一个 我们先前工作的自然延伸，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的优先事项，以增加VA工作的现实世界的影响，和VA的 总体目标是：（1）更有效地集中资源（通过指导站点实现有效和高效 （2）提高服务质量和及时性。成功完成这一创新 评价将确定利用早期评价数据为实施干预提供信息的可行性， 低性能的网站，从而提供质量改进工具，将允许VA提高有效性 以及更广泛的国家规划效率。

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.