Using QUERI & Implementation Science Theories and Frameworks to Improve Access and Equity S. Randal Henry, DPH, MPH QUERI HIV/Hepatitis C
Does implementation of disparities reduction programs differ from general quality improvement interventions?
How can implementation science contribute to disparities reduction research?
How can collaboration and partnership-building contribute to the reduction of health disparities?
How can we develop and implement programs that address the need for comprehensive, integrated care for patients with multiple co-morbid conditions that require care across multiple services lines?
The VA Healthcare System: An Ideal Environment for Disparities Research
Patients are racially and ethnically diverse and many are economically disadvantaged
Access to healthcare is similar across veteran populations, eliminating this key reason for disparities in health care
Computerized clinical and administrative national databases on veterans served
VA HSR&D and Disparities Research
The VA supports disparities research
Improving access to care and reducing health disparities is a priority research focus
Established the Center for Health Equity Research and Promotion (CHERP) and Center for Disease Prevention and Health Interventions for Diverse Populations
Does the implementation of access and equity improvement interventions differ from general quality improvement (QI) interventions?
Cyber Seminar Goals
Encourage the quality improvement community to address impaired access and inequitable distribution of care
Encourage the access and equity community to utilize implementation research
Promote the use of implementation science to reduce health disparities
The VA is committed to delivering high quality
healthcare care in an equitable manner.
What are Health Disparities?
Health disparities are differences…
in the quantity and quality of healthcare provision
in the prevalence, mortality, and burden of disease and other adverse health conditions
not due to access related factors, clinical need, preferences, or appropriateness of the intervention (IOM)
Poll Question In the course of your research or clinical practice, have you identified a health disparity? Yes? No?
Evidence of disparities
Evidence of racial and ethnic disparities in health care is consistent across a range of illnesses and healthcare services. (Smedley et al)
Disparities have been demonstrated in the Veterans Affairs (VA) healthcare system.
Smedley B, Stith A, & Nelson AR.Unequal treatment confronting racial and ethnic disparities in healthcare. City: National Academies Press (US), 2003.
Inequities within the VA
age, gender, race/ethnicity and income:
More consistently observed for processes that:
entail more risk and require more intensive decision making & communication
require more effort on the part of patients and/or providers
Associated with geographic location:
When compared to their urban counterparts, rural veterans have;
worse health-related quality-of-life
report less access to care
use fewer healthcare services
are more dependent on the VA for their healthcare services
travel burden to specialty services is substantially greater
research on rural veterans health and health care is lacking.
Saha S, Freeman M, Toure J, et al. Racial and ethnic disparities in the VA healthcare system: a systematic review. 2007 Jun. Department of Veterans Affairs HSR&D
Vulnerable Patient Groups
Low socioeconomic status
Stigmatizing medical or psychiatric illness
Disparities by QUERI
Disparities By Clinical Content Area Disparities Polytrauma and Blast Related Injuries Mental Health and Substance Use Disorders HIV/Hepatitis Chronic Heart Failure and Ischemic Heart Disease Diabetes Mellitus QUERI Group 1 6 Arthritis/pain management 2 2 Cancer treatment 2 7 Diabetes 10 20 Heart and vascular disease 3 4 HIV/Hepatitis C 10 11 Mental health/substance abuse 4 8 Preventive/ambulatory care 2 2 Rehabilitation and palliative care Not Present Present Clinical Content Area
Saha S, Freeman M, Toure J, Tippens K, Weeks C. HSR&D Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review (2007) Disparities By Utilization/Outcome Measure 1 5 Intermediate outcomes** 3 2 Patient satisfaction 2 1 Referral 10 13 Basic services/processes of care* 7 0 9 5 Medication Use Prescribing Adherence 11 21 Surgery and invasive procedures Disparities Not Present Disparities Present Utilization or Outcome Measure **E.g.: control of blood pressure, blood glucose, lipids *E.g.: lab tests, outpatient visits
Polling Questions #2
What is the key barrier to improving access and equity for veterans?
Which VA Programs Address Access and Equity?
The VA may be able to address individual and institutional barriers to care
A greater understanding of the prevalence and influence of these processes is needed and should be sought through research
Center for Health Equity Research and Promotion (CHERP)
HSR&D Center of Excellence
Promote equity and quality in health and health care
A collaboration among key entities within VISN4
Investigators played key roles in the development of Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review
VA Center for Minority Veterans
Provide and promote the use of VA programs, benefits, and services use by minority veterans
Make benefits and services more accessible to minority veterans
Evaluate current programs and make recommendations on how VA can better serve minority veterans
Office of Quality and Performance (OQP)
Operational focus on disparities
OQP custodian of rich source of data for health disparities research
OQP Chronic pain (race)
Alcohol Counseling (race)
Quality of Care (mental health, MS, SCI, Chronic illness, rural/urban)
What do you think is the major barrier to addressing disparities?
Documenting/diagnosing/identifying organizational factors that contribute to disparities
What is Implementation Science? How can it help reduce identified health disparities?
Implementation Science (IS)
Implementation Science is the study of the systematic uptake of knowledge and the implementation of that knowledge into routine organizational practice (and everything that facilitates or impedes it)
Typically conducted in health services settings
Includes examination of the influence of contextual factors (e.g. organizational policy) and individual factors (e.g. healthcare professionals) on organizational behavior
Implementation Science can…
Develop standards for evaluating access and equity
Generate new insights and generalizable knowledge regarding dissemination / implementation of disparities reduction
Develop, test and refine disparities reduction theories, hypotheses, models and principles
Determine the relative effect of quality improvement interventions among patients at highest risk for impaired access and inequitable care
Four Implementation Science Frameworks that can be used to Assess Access and Equity
CHERP Conceptual Model for Health Disparities Research First Generation Detect disparities in health or health care Second Generation Third Generation Understand reasons for disparities Develop interventions to eliminate disparities Kilbourne et al. American Journal of Public Health, December 2006
Behavioral Model of Vulnerability Chart Adapted from: Gelberg, L, Andersen RM, and Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people (2000)
f (E, C, F)
= Research; Clinical experience; Patient experience; & Local knowledge