Adapting Guideline Implementation to Local Environments (AGILE) in Primary Care After Telehealth Expansion

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PROJECT SUMMARY / ABSTRACT Urgent expansion of telehealth due to the COVID-19 pandemic may have consequences for evidence based primary care, including worsening disparities in cardiovascular disease (CVD) prevention. Implementing evidence based guidelines to reverse CVD risk would prevent more than 50% of annual deaths in middle-aged US adults but is already uneven. Guideline adherence can be improved by tailoring strategies to local barriers as in Dr. Ramly’s prior work that increased follow up on blood pressure and smoking with higher gains among Black patients. Yet tailoring is too expensive and burdensome to be used in practice and is even less feasible with the rapid telehealth expansion. There is a critical need for an alternative to tailoring to enable primary care clinics to rapidly adapt how they implement CVD guidelines after telehealth expansion to avoid worsening disparities. In engineering, configurable solutions make menus of options available to avoid expensive individual tailoring. This approach could enable clinics to use known strategies to address local barriers without engaging in an expert-led individual tailoring process. Preliminary qualitative work found many barriers to optimal care with telehealth that are modifiable with known strategies. Yet configurable solutions using known strategies have not been applied in health care despite the potential to reduce cost and reduce disparities by addressing local needs. Applying this approach will require multi-stakeholder design of a configurable toolkit informed by large clinical data and tested by a pragmatic clinical trial. Dr. Ramly’s long-term goal is to become a clinical investigator in primary care leading an independent research program to improve rapid implementation of evidence based care for chronic conditions. This 5-year K01 will fill his clinical investigation training gaps with mentored research and training in large clinical data, mixed methods, and pragmatic clinical trials. As a systems engineer faculty in a clinical department, Dr. Ramly is well prepared for a successful K01 to transition from engineer collaborator to independent clinical investigator. The overall objective of this proposal is to develop and pilot a configurable toolkit for CVD prevention. Four CVD quality metrics will be targeted: blood pressure control for patients with hypertension, and aspirin, statins, and smoking cessation for patients with coronary artery disease. The specific aims are to: 1) characterize barriers to implementation of CVD guidelines in primary care after telehealth expansion, 2) develop a configurable toolkit of strategies to address local barriers, and 3) pilot test the toolkit to assess reach, effectiveness, adoption, implementation, and maintenance, including subgroup differences. Expected outcomes are an intervention addressing a critical gap in evidence based care after telehealth expansion, with preliminary data for an AHRQ R18 trial. Dr. Ramly will become an independent clinical investigator building on prior expertise in engineering and implementation science. His current and future research aims will advance AHRQ’s mission by focusing on AHRQ-relevant priority populations (chronic conditions, older adults), problem (heart health) and emphasis (primary care).