MIDAS: Maintaining Implementation through Dynamic Adaptations

MIDAS：通过动态调整维持实施

• 批准号: 10062256
• 负责人: JACOB ELI KURLANDER
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-10-01 至 2025-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10062256
• 关键词: Academic Detailing; Acute; Address; Adopted; Adoption; Anticoagulants; Blood coagulation; Businesses; Caring; Clinic; Clinical; Cognitive Therapy; Data; Drug usage; Emergency department visit; Ensure; Evidence based practice; Funding; Gastrointestinal Hemorrhage; Goals; Guidelines; Health system; Healthcare Systems; Heart Abnormalities; Hospitalization; Individual; Institutionalization; Learning; Letters; Measures; Mental Health; Modernization; Oral; Outcome; Patients; Performance; Pharmaceutical Preparations; Pharmacology; Positioning Attribute; Process; Proton Pump Inhibitors; Provider; Randomized Controlled Trials; Recording of previous events; Scientific Advances and Accomplishments; Site; Sleep; Sleeplessness; Suicide prevention; System; Training Programs; Upper digestive tract structure; Veterans; Work; arm; authority; base; burnout; clinical care; compare effectiveness; cost; design; dosage; effective therapy; experience; heart rhythm; high risk; hospital utilization; iatrogenic injury; implementation efforts; implementation strategy; improved; learning strategy; member; older patient; operation; pharmacy benefit; prevent; programs; recruit; side effect

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.

Midas Queri的总体目标是减少实施循证实践的变异性 （EBP）通过针对晚期采用者。如果数据表明即使在护理中的差距，则将中心视为较晚的采用者 已经采取了全国实施努力来增加对EBP的使用。我们将帮助实现VHA 成为一个高可靠性组织（HRO）的现代化计划目标，致力于零危害。这三个 我们的EBP专注于减少潜在的有害药物习惯，并用更多 适当的疗法。我们提议的Midas Queri将专注于维持（又称维持）变化 旨在改善护理，特别是针对实施工作的实践 全国。我们的实施方法旨在使临床医生和团队在前线与 识别和实施繁忙临床可行的增量变化的动态过程 设置。我们的方法将导致临床过程和三个EBP的适应。 Midas Queri的实施核心将增加我们合作伙伴以前的国家实施工作 还有两种促进EBP持续使用的策略：学习。从事。行为。过程。 （LEAP）质量改进（QI）培训计划和增强的学术细节（EAD）。 Leap，那是 最近作为“实施中心”的一部分资助，已经被公认为是实践的宝贵策略 更改并包括在VHA的在线市场中。我们将进行群集随机对照试验 （CRCT）严格比较这些策略，并结合使用。我们将集中精力 维持三个EBP的维持努力，所有这些都是我们运营伙伴的优先事项： 项目1：优化使用质子泵抑制剂以最大程度地减少医源性损伤，包括上胃肠道出血。 这包括两个子项目：1A）解决PPI的不足；和1b）解决PPI的过度使用。我们的 这些项目的运营合作伙伴分别是Visn 10和药房福利管理（PBM）。 项目2：更安全地使用直接口服抗凝剂（DOAC）来减少可预防的急诊室就诊。我们的 国家运营伙伴是PBM，我们的VISN合作伙伴是Visn 15。 项目3：越来越多地使用认知行为疗法对失眠（CBTI）而不是药理 睡眠有助于作为失眠症的一线治疗。我们的运营伙伴是心理健康办公室 和预防自杀（OMHSP）。 我们将根据表明实施不足的指标招募每个项目的12个晚期采用者网站 参加国家实施计划之后的EBP。我们的具体目的是： 特定目标1：通过增加在延迟添加的VHA设施中采用三个EBP来改善临床护理。 对护理的影响将通过接受准则协调的合格患者百分比来衡量 药物和剂量（项目1和2），以及接受指南一致的合格患者的百分比 治疗（项目3）。这些临床结果有望减少ED访问（项目1和2），百分比为 高风险药物（项目3）和急性医院利用率（项目1、2和3）的老年患者。 特定目的2：比较三种实施策略的有效性：LEAP与EAD，与 leap+ead。我们将在每个项目中进行群集随机对照试验（CRCT）以进行比较 策略；我们还将在每个实施策略中跨项目跨项目结合以比较 策略。结果将与目标1相同。 特定目标3：让临床团队参与动态，增量适应以维持EBP的使用。在两个 获得飞跃的三个CRCT武器，我们将收集：1）一线团队的程度 继续进行QI活动； 2）团队成员的倦怠； 3）衡量团队制造和维持的能力 改变; 4）联邦最佳工作场所。