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.

肝硬化或晚期肝脏疾病是美国的第四个领先，最快的死亡原因 那些年龄在45-64岁之间的人列为美国总体死亡率过剩的前三名。几乎 在退伍军人医疗保健管理局（VHA）护理下的120,000名退伍军人由于 酒精，丙型肝炎，脂肪肝病或其他原因，这一数字正在迅速增加。有生活 - 提供者可以采取的节省措施，以防止肝硬化危害，包括提供访问后 放电肝癌和食管静脉曲张的筛查（可能引起的静脉 灾难性的出血）。但是，不到30％的退伍军人与这三个接受一致的护理 循证实践（EBP）。因此，我们的手术伙伴，艾滋病毒，肝炎和相关 条件计划办公室（HHRC）创建了一种学习协作，以改善cirhosis EBP的吸收 VA。作为这个肝创新团队（HIT）合作的评估团队，我们已经开发了这个 应与HHRC的要求和合作的合作评估计划。通过这个PEI，我们的目标是 了解用于促进EBP的实施策略或开展的离散活动 实施可以帮助改善EBP的肝硬化护理的吸收。我们的具体目的是：1） 经验上确定实施策略的哪些组合与 成功实施了肝硬化的退伍军人； 2）使用干预映射到 操作这些“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增加混合III类型中的肝硬化EBP吸收 楔形群集随机试验。为了实现这些目标，我们对73个实施进行了调查 通过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，在130个VA站的全国响应率最高为84％。我们将管理 对所有VA站的调查，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网站级别遵守EBP有关 然后，我们将使用干预映射，这是一个系统的，一个系统的，利益相关者驱动的六步过程，用于 制定干预措施和实施策略，以将这些策略发展为手动， 促进干预措施，在综合促进的卫生实施行动研究的指导下 服务（I-Parihs）框架。然后，我们将在12个站点中测试此实施策略捆绑包 使用阶梯楔形设计遵守肝硬化的退伍军人的EBP，其中四个地点将越过 控制大约每6个月一次干预。我们将评估实施的影响 干预患者水平准则指定符合护理的主要结果以及多种措施 实施（例如，改编，维护）。我们的工作是应合作伙伴HHRC的要求，我们有 还与以下中心和Queris的调查人员合作：国家肝财团 重新设计护理（NCRC），Bridgequeri，基于团队行为健康的QuERI，精确监控 转变护理（PRIS-M）Queri和医疗保健转型办公室（OHT）。这个项目是 自然扩展我们先前的工作，并与HSR＆D的优先级保持一致 科学与测量方法，Ord的优先事项是增加VA工作的现实影响，而VA 总体目标（1）更有效地集中资源（通过指导网站朝着有效而有效 实践）和（2）提高服务的质量和及时性。成功完成了这一创新的 评估将确定使用早期评估数据为实施干预措施的可行性 表现不佳的站点，从而提供质量改进工具，使VA能够提高有效性 以及更广泛的国家编程的效率。

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.