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 的总体目标是减少基于证据的实践实施的可变性 （EBP），如果数据差距表明即使在之后的护理中，中心也会被视为后期采用者。 国家已做出努力来增加 EBP 的使用，我们将帮助实现 VHA。 现代化计划的目标是成为高可靠性组织 (HRO)，致力于实现这三项零伤害。 我们的 EBP 专注于减少潜在有害的用药实践并用更多的药物替代 我们提出的 MIDAS QUERI 将侧重于维持（又名维持）变化。 旨在改善护理，特别是已推出有针对性的实施工作的做法 我们的方法是在全国范围内实施，旨在让一线的忠诚者和团队参与进来。 识别和实施在繁忙的临床中可行的增量变化的动态过程 我们的方法将导致临床流程和三个 EBP 的调整。 MIDAS QUERI 的实施核心将增强我们合作伙伴之前的国家实施工作 还有两个促进 EBP 持续使用的策略：学习过程。 (LEAP) 质量改进 (QI) 培训计划和增强的学术细节 (eAD)。 最近作为“实施中心”的一部分获得资助，已被认为是一项有价值的实践策略 更改并包含在 VHA 的在线市场中，我们将进行整群随机对照试验。 （cRCT）严格比较这些单独实施和组合实施的策略。 三个 EBP 的维持工作，所有这些都是我们运营合作伙伴的优先事项： 项目 1：优化质子泵抑制剂的使用，以尽量减少医源性损伤，包括上消化道出血。 这包括两个子项目：1a）解决 PPI 使用不足的问题；1b）解决 PPI 过度使用的问题。 这些项目的运营合作伙伴分别是 VISN 10 和药品福利管理 (PBM)。 项目 2：更安全地使用直接口服抗凝剂 (DOAC)，以减少可预防的急诊室就诊。 国家运营合作伙伴是 PBM，我们的 VISN 合作伙伴是 VISN 15。 项目 3：增加使用认知行为疗法治疗失眠 (CBTI) 而不是药物治疗 睡眠辅助剂作为失眠症的一线治疗方法我们的运营合作伙伴是心理健康办公室。 和自杀预防 (OMHSP)。 我们将根据证明不足的指标，为每个项目招募 12 个后期采用者实施站点 参与国家实施计划后 EBP 的具体目标是： 具体目标 1：通过在较晚采用的 VHA 机构中增加采用三种 EBP 来改善临床护理。 对护理的影响将通过接受符合指南的患者的百分比来衡量 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）。这些临床结果预计会减少急诊就诊（项目 1 和 2）的百分比。 服用高风险药物的老年患者（项目 3）以及急性医院利用率（项目 1、2 和 3）。 具体目标 2：比较三种实施策略的有效性：LEAP 与 eAD、与 我们将在每个项目内进行整群随机对照试验（cRCT）进行比较。 策略；我们还将结合每个实施策略中跨项目的数据进行比较 结果将与目标 1 的结果相同。 具体目标 3：让临床团队参与动态、渐进的调整，以维持 EBP 的使用。 对于接受 LEAP 的三个 cRCT 分支，我们将收集以下指标： 1) 一线团队的参与程度 持续的 QI 活动；2) 团队成员的倦怠；3) 衡量团队制定和维持的能力； 变化；以及 4) 联邦最佳工作场所衡量标准。