Multiple Methods of Implementing Evidence Based Best Practices: Examples from QUERI Health Services Research & Development Service Department of Veterans Affairs Knowledge Utilization International Conference Quebec, Canada September 25, 2003 Quality Enhancement Research Initiative
The beneficial effect of simvastatin in individual patients in 4S was determined mainly by the magnitude of the change in LDL-c (1).
Each additional 1% reduction in LDL-c reduces MCE (IHD death and nonfatal MI) risk by 1.7% (1).
Heart Protection Study: RCT with Simvastatin decreased mortality in a broad range of patients and reduced MI and stroke by one-third (2).
Simvastatin Survival Study Group. Lipoprotein changes and reduction in the incidence of major coronary heart disease events in the Scandinavian Simvastatin Survival Study (4S). Circ 97:1453-1460; 1998.
Audit/Feedback: Providers were e-mailed a list of IHD patients ranked by LDL-c level excluding patients without LDL measurement
98 providers in all firms were sent e-mails
Pharmacist Case Management: Pharm D Resident identified high-risk patients and intervened with providers and their patients in one clinic.
PharmD only intervened with 5 patients during the time of the intervention.
Process Variables and Outcomes for Site B Audit/Feedback intervention starts May 2000 and continues until Jan 2001 Pharmacist case management intervention starts Pharmacist case management intervention ends
Providers were e-mailed a list of IHD patients ranked by LDL-c level;
IHD patients were sent a letter stating the importance of maintaining a LDL-c cholesterol below 100 mg/dL, a brochure, and two pages of resources
Process and Outcome Variables for Site C Kickoff Meeting on site Providers were sent an e-mail informing them of the interventions 632 letters were sent to patients Providers were sent a list of IHD patients with rank order of LDL
Cardiology Clinic I: Paper POC Reminder: Initiated by Cardiology Coordinator. Continues today
Home Site: Computerized Order template adds fasting lipid panels to cardiac cath and cardiology admissions. Continues today
Process Variables and Outcomes for Site D Kickoff Meeting In-service at primary care staff meeting at satellite clinic Paper POC reminder in cardiology clinic at Satellite Cardiology Clinic Fasting lipid panel added to order template in CPRS (cardiology admissions and cath patients) CCU informational In-service for nursing staff in Home Site
Process Variables and Outcomes for Site E Lipid Clinic Starts Kickoff Meeting In Seattle CME Meeting: with national expert and LMMS Research Staff *Clinical pharmacist leaves VA* PharmD starts PharmacoManagement Clinic PharmD receives permission to call patients on Seattle Data list
ER orders for IHD patients were changed to add lipid profile & LFTs; Start Simvastatin, review ASA, ACE inhibitor, B-blocker use; repeat LFTs & lipids in 6 weeks
Admission orders for ICU/ACU changed to include LFTs and statins w/6 week f/u
Target education program for nursing staff
Pharmacist-run Lipid Clinic
Process and Outcome Variables for Site F Addition to computerized order templates to include fasting lipid profile and Simvastatin Kickoff meeting in Seattle Nursing/Pharmacy/MD Staff IHD Education Pharmacist-run Lipid Clinic opens in October 2000
A sheet was placed in front of the patient’s chart at the time of the appointment.
The sheet contained lab information, pharmacy information and text lines for a provider response to the reminder.
Process and Outcome Variables for Site G Kickoff Meeting in Seattle Intervention is presented to Medical Staff QA manager distributed a copy of the LMMS report to providers The Paper POC reminder intervention starts Intervention ends
Appointment times too short to accomplish preventive care
No opinion leader
No follow-up to promote physician response
Lack of intervention team time to promote intervention
VA providers are more conscientious about meeting guidelines than private sector providers
Buy-in was good because of evidence basis of intervention
Site H Electronic Clinical Reminder Intervention
When interventionists returned from Seattle kickoff meeting they presented the electronic clinical reminder to providers during a staff meeting and an e-mail
In August 1999 the IHD-PCE reminder was turned on for providers
One of the interventionists received patient data in early Jan 2000.
Process and outcome variables in Site H Kickoff Meeting in Seattle Intervention team presents study and intervention to provider staff @ Staff Meeting IHD-PCE Reminders are turned on Patient list is sent by Seattle team