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TIARA Module 4 Geoff Barnes 10302019

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Training in Implementation: Actionable Research Approaches (TIARA): Module 4, Practical Considerations

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TIARA Module 4 Geoff Barnes 10302019

  1. 1. Implementation Science in Action: A Case Study of Antithrombotic Management before GI Endoscopy Geoff Barnes, MD, MSc October 30, 2019
  2. 2. Implementation Process Framework
  3. 3. Antithrombotic Medications JAMA Network Wikipedia 3-6 Million Americans with AFib ~1million coronary stents annually
  4. 4. Antithrombotic Medications and Procedures • #1 Cause of “Adverse Drug Events” • Medications  Prevent clots • Surgery  Need to clot • When to stop meds before surgery? • Depends on medication • Need for a short-term “bridge”? JAMA 2016;316:2115-25
  5. 5. Antithrombotic Medications and Surgery Atrial Fibrillation Surgical Procedures Complicated peri-procedural anticoagulation >500,000 annual patients Barnes Am J Med 2015;128:1300-5 Mozaffarian Circ 2015;131:e29-322
  6. 6. Conceptual Model for Periprocedural Anticoagulation
  7. 7. Step 1: Assess Practice Gaps 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CHADS=1 No Prior Stroke CHADS=3 No Prior Stroke CHADS=3 Prior Stroke CHADS=5 Prior Stroke Cardiology Gastroenterology Internal Medicine Family Medicine JAMA Cardiol 2016;1:1076-7 Am J Cardiol 2018;121:1548-1551
  8. 8. Step 1: Assess Practice Gaps JAMA Cardiol 2016;1:1076-7 32% 68% PCP Comfort Uncomfortable Comfortable 82% 18% PCP Need Help Yes No
  9. 9. Step 1: Assess Current Process Project Team • Physicians • Cardiology/Anticoagulation • GI • PCP – Internal Medicine • PCP – Family Medicine • OB/GYN • Anticoagulation Clinic • Pharmacist • Nursing • GI Clinic • GI Endoscopy • Scheduler • GI Endoscopy • Patients • IT • Performance Improvement
  10. 10. Step 1: Assess Current Process Current State Process Map
  11. 11. Step 1: Assess Current Process Baseline Metrics • EMR data • 4 endoscopic cases daily on antithrombotic agents • Patient phone calls • 15% dissatisfied with care coordination/communication • Endoscopy nurses tally sheet • 16% of patients mismanage medications • 6% of patients have cases canceled
  12. 12. Step 1: Assess Current Process Root Cause Analysis
  13. 13. Step 2: Assess Evidence Base to Reduce Gap NEJM 2015; 373(9):823-33
  14. 14. NNH = 53 NNH = 11 NNH = 53 NNH = 11 NEJM 2015; 373(9):823-33
  15. 15. Step 2: Assess Evidence Base to Reduce Gap Literature Review with Clinical Experts for Anti-platelet guidelines
  16. 16. Step 3: Assess Barriers/Facilitators How to Reorganize? Guiding Principles • Accountable to patient • Health system “owns” coordination (not patient) • Transparency to all providers and patients • Consistent, evidence-based practice • Robust process (internal and external referrals) • Minimize reliance on human case identification (use EMR triggers)
  17. 17. Step 3: Assess Barriers/Facilitators Potential Solutions Primary Care Provider • Most knowledge of patient and current medications • Scalable to other procedures • Lack of comfort with decision-making • Difficult to standardize practice • How to influence non-UM docs? GI Docs/Nurses • Most knowledge of procedure • Lack of comfort with decision-making • Constrained resources • Not scalable to other procedures Anticoagulation Clinic • Knowledgeable about medications • Similar work for cardiac catheterization • Available resources • Scalable to other procedures • Lack of procedure familiarity • Need delegated MD authority
  18. 18. Step 3: Assess Barriers/Facilitators Develop Implementation Plan Implementation Science 2013;8:35 TICD Checklist • Combined from 12 frameworks & checklists • 7 domains • Guideline Factors • Individual Health Professional Factors • Patient Factors • Professional Interactions • Incentives and Resources • Capacity for Organizational Change • Social, Political, and Legal Factors
  19. 19. Step 3: Assess Barriers/Facilitators Develop Implementation Plan Implementation Science 2013;8:35 Most Important Potential Barriers • Quality/Strength of Evidence (Warfarin, DOAC, P2Y12) • Feasibility & Accessibility of Intervention/Effort of Behavior • Referral Process • Patient Beliefs and Knowledge • Communication and Influence • Influential People
  20. 20. Step 4: Link Barriers to Evidence-based Change Techniques (ERIC) • Build a coalition • Involve patients • Use data experts • Identify and prepare champions (GI, Int Med, Fam Med, Gyn) • Organize clinician implementation team meetings • Obtain and use patient feedback • Develop a formal implementation blueprint (A3) • Inform local opinion leaders (GI endoscopy leads) • Alter incentive structure (make it easiest to follow pathway) • Provide clinical supervision (for pharmacists) • Conduct educational outreach visits (endoscopy nursing) • Conduct educational meetings • Stage implementation scale up (start with pilot clinics) • Purposefully reexamine the implementation (meetings during/after pilot) Imp Sci 2015;10:21
  21. 21. Implementation Blueprint – A3 Am J Med Qual 2019 ePub Oct 4
  22. 22. Implementation Blueprint – A3
  23. 23. Step 5: Develop Implementation Intervention Future State: Swim Lane Process Map Peri-Endoscopy Anticoagulation/Antiplatelet Management – Future State Last Revised: August 9, 2017 Ordering Physician SchedulerAnticoagTeam Endoscopy PrepRN GIPhysicianGINurse NON UMHS: Faxes Direct Access Endoscopy Referral form to call center Receives call from check out staff OR calls patient directly to schedule procedure, reviews medications based on exclusion criteria, describes the anticoag referral process and sends detailed itinerary with further instructions Receives anticoag referral in MiChart 1-2 weeks before procedure, call patient to review coordination of care and send further instructions (mail, portal) Two weeks before patient’s procedure, review protocol 1)Need multi-provider discussion? 2) Refer to GI clinic? 3) Delay procedure? Perform med reconciliation during patient prep Performs procedure Documents post procedure instructions and sends report to ordering MD Discusses need for procedure with patient = Patient Touch Point MiChart order will default to Anticoag team referral unless MD indicates he/ she will manage Patient provided AVS and follow up instructions Creates and pends an anticoag referral UMHS: MD places order and patient is flagged in MiChart based on antithrombotic therapy Transcribes order from non-UMHS physician and sends InBasket message to GI RN Place JIT reminder call (if needed) to patient (as identified through previous contact)) to take med action Signs anticoag referral from nonUMHS provider
  24. 24. Step 5: Develop Implementation Intervention Best Practice Advisory Key Design Features • Automated • Minimal work disruption • Opt out (not opt in) • Simple to document why “opting out” • Ability to “customize” and communicate with PharmD
  25. 25. Implementation Process Framework
  26. 26. Timeline • Spring 2017 • Form QI/Implementation Team • Bi-weekly meetings • Summer 2017 • Build BPA and plan Implementation • Fall 2017 • Pilot implementation • Winter/Spring 2018 • Health System-wide Implementation • Summer 2018 • Initial Data Collection • Fall 2018-Fall 2019 • Follow up Data Collection
  27. 27. Outcome Measurement • Process Use • Provider Satisfaction • PCP • GI • Nursing • Anticoagulation Staff • Patient Satisfaction • Cancelation Rate • Adherence to Guidelines • Use of bridging LMWH for warfarin • When DOACs are stopped • Adverse Events • Bleeding • Thrombotic • Resource Utilization • Anticoagulation Staff
  28. 28. Initial Outcomes Data 66.7% of Cases with Referral
  29. 29. Initial Outcomes Data Baseline (Fall 2017) Post-Implementation (Fall 2018) Inappropriate Med Management on Endoscopy Day 16% 2% Same-day Endoscopy Canceled 6% 2% Patients Satisfied with Communication & Coordination 85% 95% Cancelation within 24 hours of procedure: 9.4%  7.5% (p=0.024) • Estimate $250,000 annual savings in lost billing
  30. 30. Initial Outcomes Data – Provider Survey
  31. 31. Implementation Process Framework

Training in Implementation: Actionable Research Approaches (TIARA): Module 4, Practical Considerations

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