QUERI – Quality Enhancement Research Initiative

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MedSafe

Palo Alto, CA

Principal Investigators: Paul Heidenreich, MD, MS (Corresponding PI, VA Palo Alto), and Mary Goldstein, MD (VA Palo Alto)

Principal Operational Partners: VA Office of Pharmacy Benefits Management (PBM), VISN 21 Pharmacy Benefits Management (VISN 21 PBM), VA Office of Primary Care Services (PCS), and the VA Office of Specialty Care Services (SCS).

Executive Summary:

The main theme of the MedSAFE QUERI Program is optimization of medication use with decision support and provider networks as the focus of implementation. The underlying principle is to promote high-value clinical care with all medication related interventions. While VA has implemented many interventions to improve medication safety, medication management has significant room for improvement. A large variation in the quality of medication prescribing has been noted in the VA, which is comparable to the general population. There also is variation in the quality of prescribing across disease states in the VA healthcare system. MedSAFE QUERI will address high-risk medications that require routine monitoring, and will only recommend expansion or design interventions for care strategies that are considered a "reasonable" value (ratio of benefit and cost).

The MedSAFE QUERI program takes advantage of several natural experiments that have occurred through variable implementation of medical safety programs. It will build upon existing strong relationships between the project leads (who have a long history of conducting successful QUERI projects), and their operations partners including VA Office of Pharmacy Benefits Management (PBM), VISN 21 Pharmacy Benefits Management (VISN 21 PBM), Primary Care Services (PCS), Specialty Care Services (SCS), and Primary Care Services.

Program Objectives:

To optimize medication management in the VA general and Patient-Aligned Care Teams, in particular, using pharmacy networks and decision support tools. While VA has implemented many interventions to improve medication safety, medication management has significant room for improvement. Several recommendations by the Institute of Medicine, including the wide availability of decision support and more pharmacy involvement in prescribing, have not been widely implemented in the VA. In 2011, 12% of Veterans were prescribed a potentially inappropriate medication with an incidence (new inappropriate medication) of 6% per year. Moreover, a large variation in the quality of medication prescribing has been noted in the VA, which is comparable to the general population. There also is variation in quality of prescribing across disease states in the VA.

Program Objectives:

MedSAFE QUERI's primary program objective is to optimize medication management in the VA general and Patient Aligned Care Teams in particular using pharmacy networks and decision support tools. Investigators will build a high-performance healthcare network and improve employee engagement. The underlying principle is to promote high-value clinical care with all medication related interventions. Investigators will only recommend expansion of, or design interventions for care strategies that are considered a "reasonable" value (ratio of benefit and cost), in order to to improve use of high value medications, decrease use of low-value medications, and improve medication safety.

Program Methods:

MedSAFE QUERI plans to optimize infrastructure and implementation strategies using local providers, clinical decision support, and, dashboard data that can be used for a variety of clinical decisions beyond medication management, such as elicitation of patient goals of care or monitoring functional status in patients with multiple morbidities. By taking advantage of natural experiments that have occurred as different facilities implemented the MUET (Medication Use Evaluation Tracker) program and VISN 21 Pharmacy Dashboard differently, investigators will be able to examine effectiveness and value of a variety of implementation strategies.

This QUERI program is guided by the following conceptual models:

  • Ottawa Model for Research Use, and
  • Consolidated Framework for Implementation Research (CFIR)

Project Summaries:

Project 1: Optimization and expansion of the Medication Use Evaluation Tracker (MUET) of PBM.

Through MedSAFE QUERI's long-standing partnership with PBM, they will perform a national evaluation of the effectiveness of the five MUET programs of PBM, compare the effectiveness and associated resource uses of different implementation strategies employed by pharmacists using MUET at different VA facilities, and facilitate use of the optimal implementation strategies for existing programs and for a new MUET program.

Project 2: Implementation of Clinical Decision Support (CDS) for medications commonly prescribed in Primary Care Services. This project will support evidence-based best practices for managing five common chronic conditions by implementing CDS in the VISN 21 Clinical Dashboard for Patient Aligned Care Teams PACTs. By working with PACTs, MedSAFE QUERI will determine the most effective strategies to integrate CDS use into clinical workflow. The project will develop structures that can be readily adapted to clinical decision-making about additional conditions as new guidelines, clinical consensus, and patient data become available.

Project 3 (Quality Improvement): Determine optimal use of the VISN 21 Pharmacy Dashboard targeting Patient Aligned Care Teams. MedSAFE QUERI investigators will evaluate the effectiveness of the VISN 21 PBM Pharmacy Dashboard designed to improve the safety of mineralocorticoid receptor antagonists (MRAs), methotrexate, and sulfasalazine. They will compare the effectiveness and associated resource uses of different implementation strategies employed by the different facilities within VISN 21 – and promote at least one of the identified implementation strategies to all VISN 21 facilities.