MIDAS: Maintaining Implementation through Dynamic Adaptations

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MIDAS QUERI’s overarching goal is to reduce the variability in implementation of evidence-based practices (EBPs) by targeting late adopters. A center is considered a late adopter if data indicate gaps in care even after national implementation efforts have been made to increase use of an EBP. We will help achieve VHA’s Modernization Plan goal to become a High Reliability Organization (HRO), committed to zero harms. All three of our EBPs focus on reducing potentially harmful medication practices and substituting them with more appropriate therapy. Our proposed MIDAS QUERI will focus on Maintaining (aka sustaining) changes designed to improve care, specifically practices that have had targeted Implementation efforts rolled out nationally. Our implementation approaches are designed to engage clinicians and teams at the frontline in a Dynamic process of identifying and implementing incremental changes that are feasible within busy clinical settings. Our approach will lead to Adaptations of clinical processes and the three EBPs. The MIDAS QUERI’s Implementation Core will augment our partners’ prior national implementation efforts with two additional strategies for promoting sustained use of the EBPs: the Learn. Engage. Act. Process. (LEAP) quality improvement (QI) training program and enhanced Academic Detailing (eAD). LEAP, which was recently funded as part of an “Implementation Hub,” is already recognized as a valuable strategy for practice change and is included in VHA’s Online Marketplace. We will conduct cluster randomized controlled trials (cRCTs) to rigorously compare these strategies delivered alone and in combination. We will focus our sustainment efforts across three EBPs, all of which are priorities of our operational partners: Project 1: Optimizing use of proton pump inhibitors to minimize iatrogenic injury, including upper GI bleeding. This includes two sub-projects: 1a) addressing underuse of PPIs; and 1b) addressing overuse of PPIs. Our operations partners in these projects are VISN 10 and Pharmacy Benefits Management (PBM), respectively. Project 2: Safer Use of Direct Oral Anticoagulants (DOACs) to reduce preventable emergency room visits. Our national operations partner is PBM and our VISN partner is VISN 15. Project 3: Increasing use of Cognitive Behavioral Therapy for Insomnia (CBTI) rather than pharmacologic sleep aids as a first-line treatment of insomnia disorder. Our operations partner is the Office of Mental Health and Suicide Prevention (OMHSP). We will recruit 12 late adopter sites per project based on metrics demonstrating inadequate implementation of the EBP following participation in a national implementation program. Our specific aims are: Specific Aim 1: To improve clinical care by increasing adoption of three EBPs in late-adopting VHA facilities. Impact on care will be measured by the percentage of eligible patients receiving guideline-concordant medications and dosages (Projects 1 and 2), and percentage of eligible patients receiving guideline concordant therapy (Project 3). These clinical outcomes are expected to reduce ED visits (Projects 1 and 2), percentage of elderly patients on high risk medications (Project 3), and acute hospital utilization rates (Projects 1, 2, and 3). Specific Aim 2: To compare the effectiveness of three implementation strategies: LEAP versus eAD, versus LEAP+eAD. We will conduct cluster randomized controlled trials (cRCTs) within each project to compare strategies; we will also combine data across projects within each implementation strategy to compare strategies. Outcomes will be the same as those for Aim 1. Specific Aim 3: To engage clinical teams in dynamic, incremental adaptations to sustain EBP use. In two of the three cRCT arms that receive LEAP, we will collect measures of: 1) the extent to which frontline teams are continuing QI activities; 2) burnout among team members; 3) a measure of teams’ ability to make and sustain change; and 4) the Federal Best Places to Work measure.