Classifying the effectiveness of Veterans Affairs guideline implementation approaches

Getting a clinical innovation into practice: An introduction to implementation strategies

Just as there is a robust science that supports development and rigorous testing of clinical innovations, the emerging field of implementation science is developing new theory-based knowledge regarding a growing portfolio of meticulously tested implementation strategies that seek to improve uptake of evidence-based practices by targeting barriers at multiple levels within health care settings. Studying and documenting implementation strategies associated with uptake during the development and trial of a clinical innovation could subsequently position the researcher for a more seamless transition and handoff of the innovation to clinical and operational leaders. The objective of this manuscript is to introduce the concept of implementation strategies: what they are; the rigor with which they are defined and applied to address barriers to clinical innovation adoption; how strategy selection may vary based on contextual, innovation, and recipient factors; how to document the application of strategies over the course of an implementation study; and how testing their effectiveness is the focus of implementation research trials.

The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance

BACKGROUND

The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs.

METHODS

Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models.

RESULTS

For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used.

CONCLUSION

Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.

Translating research into practice intervention improves management of acute pain in older hip fracture patients

OBJECTIVE

To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults.

STUDY DESIGN

Experimental design with the hospital as the unit of randomization.

STUDY SETTING

Twelve acute care hospitals in the Midwest.

DATA SOURCES

(a) Medical records (MRs) of patients > or =65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients.

DATA COLLECTION

Data were abstracted from MRs and questions distributed to nurses and physicians.

PRINCIPAL FINDINGS

The Summative Index for Quality of Acute Pain Care (0-18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001).

CONCLUSION

The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.

Information technology to support improved care for chronic illness

BACKGROUND

In populations with chronic illness, outcomes improve with the use of care models that integrate clinical information, evidence-based treatments, and proactive management of care. Health information technology is believed to be critical for efficient implementation of these chronic care models. Health care organizations have implemented information technologies, such as electronic medical records, to varying degrees. However, considerable uncertainty remains regarding the relative impact of specific informatics technologies on chronic illness care.

OBJECTIVE

To summarize knowledge and increase expert consensus regarding informatics components that support improvement in chronic illness care.

DESIGN

A systematic review of the literature was performed. "Use case" models were then developed, based on the literature review, and guidance from clinicians and national quality improvement projects. A national expert panel process was conducted to increase consensus regarding information system components that can be used to improve chronic illness care.

RESULTS

The expert panel agreed that informatics should be patient-centered, focused on improving outcomes, and provide support for illness self-management. They concurred that outcomes should be routinely assessed, provided to clinicians during the clinical encounter, and used for population-based care management. It was recommended that interactive, sequential, disorder-specific treatment pathways be implemented to quickly provide clinicians with patient clinical status, treatment history, and decision support.

CONCLUSIONS

Specific informatics strategies have the potential to improve care for chronic illness. Software to implement these strategies should be developed, and rigorously evaluated within the context of organizational efforts to improve care.

Facility-level factors influencing chronic heart failure care process performance in a national integrated health delivery system

BACKGROUND

Gaps between evidence and practice in the care of patients with chronic heart failure (CHF) in the United States suggest major opportunities for improvement. However, the organizational factors and implementation approaches that influence adherence to national guidelines are poorly understood.

OBJECTIVES

The objectives of this study were to explore the degree to which providers in the Veterans Health Administration system adhere to CHF clinical practice guidelines, and to identify facility-level factors influencing adherence.

DESIGN

In a national cross-sectional study, facility quality managers were surveyed regarding quality improvement efforts, guideline implementation, and context. These data were linked to organizational structure data and provider adherence data from chart reviews. The unit of analysis was the facility. The data were adjusted for the average number of comorbidities per CHF patient. Multivariate logistic regression models were constructed to model factors affecting adherence to CHF guidelines.

SAMPLE

The sample consisted of 143 Veterans Administration Medical Centers with ambulatory care clinics.

RESULTS

The quality manager survey included data from 91% of facilities. Facility-level estimates of provider adherence measures were, on average, 85% or more for most measures. In multivariate analyses, facilities with higher levels of adherence were more likely to have: (1) providers who had been given a brief guideline summary, (2) providers receptive to the guidelines, (3) guideline-specific task forces to support implementation, and 4) a well-planned implementation process.

CONCLUSIONS

Healthcare organizations should adapt implementation to meet local conditions, including creating guideline-specific task forces, developing a well-planned implementation process, fostering provider buy-in, and providing guideline summaries to providers.