Peer learning to promote quality and appropriate use of percutaneous coronary intervention

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Dr. Jacob Doll, MD is a Staff Interventional Cardiologist at the VA Puget Sound Health Care System, Acting Assistant Professor in the University of Washington Department of Medicine, Core Investigator at the Seattle HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, and Assistant Director of the VA Clinical Assessment, Reporting, and Tracking (CART) program. The proposed Career Development Award (CDA) will benefit Veterans by improving the delivery of invasive cardiac care through peer learning strategies, while provide the training and support Dr. Doll needs to become a leader in performance evaluation and feedback and to drive innovation in cardiovascular procedural care. This research will develop and test a peer learning intervention that promotes percutaneous coronary intervention (PCI) care quality. PCI, also known as “stenting,” is a common cardiovascular procedure that can improve survival and quality of life when used appropriately. However, clinical outcomes vary significantly among hospitals and physicians. Nearly all PCI procedures in the US are reported to national registries for quality improvement purposes, including the CART program. Despite this wealth of clinical data and substantial investment of time and resources to PCI quality, physicians who perform PCI are not receiving meaningful feedback about their practice. Improved methods of audit and feedback are needed. Peer learning is a collaborative quality improvement method that provides detailed, personalized, and actionable feedback to clinicians from their colleagues. The performance of unnecessary PCI procedures and the technical quality of procedures are of particular interest to VA. Of elective procedures performed at VA, only 24% are clearly indicated by appropriateness criteria, potentially putting patients at risk without benefit. The nominee for this CDA therefore proposes to design and test a peer learning intervention that promotes PCI quality and appropriate case selection. The specific aims of the proposal are: 1) Identify barriers and facilitators to the use of peer learning through surveys and semi-structured interviews with VA PCI operators and key stakeholders; 2) Develop and refine a peer learning intervention that provides usable and acceptable feedback to PCI operators; and 3) Pilot test a peer learning intervention to assess and improve PCI case selection and technical performance. This research will directly benefit Veterans and the VA system by improving the quality of PCI and increasing the frequency of appropriate PCI, thereby maximizing benefit while avoiding unnecessary procedural risks and costs. It will build on the extensive ongoing investment in the CART program by developing a novel method for promoting clinical practice change. Finally, it will develop methods of peer learning that are broadly applicable to other fields. The research program will lead directly to a multi-site randomized controlled trial and ultimately to the development of a national collaborative peer learning system that promotes physician development and care quality. To achieve his research and career goals, Dr. Doll will acquire additional skills in qualitative methods, implementation science, behavior change interventions, and trial design through coursework and directed study. His research and training plan will be supported by a diverse and well-qualified mentorship team that includes David Au, MD, MS (behavior change interventions, implementation of health programs, clinical trials), Sunil Rao, MD (interventional cardiology care quality, clinical trials, observational research), Robb MacLellan, MD (career development, physician training, quality improvement), and Christian Helfrich, PhD, MPH (implementation science, behavior change interventions). This proposed CDA research, in combination with robust mentorship and training plans, will accelerate Dr. Doll's independence as a physician-scientist and leader in cardiovascular medicine.