QUERI – Quality Enhancement Research Initiative

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Improving Safety and Quality through Evidence-Based De-Implementation of Ineffective Diagnostics and Therapeutics

Puget Sound, WA

Principal Investigators: David Au, MD (Corresponding PI, VA Puget Sound), Christian Helfrich, PhD (VA Puget Sound), Adam Rose, MD (Bedford VA); Christine W. Hartmann, PhD

Principal Operational Partners: Pharmacy Benefits Management (PBM) Services and Specialty Care (SCS).

Executive Summary:

The Choosing Wisely initiative is a program to de-implement low-value practices that can provide an effective message to simultaneously improve quality and value. However, while Choosing Wisely identifies targets for de-implementation, it does not speak to what strategies may help achieve this goal. While much is known about effective implementation strategies, little is known about effective de-implementation strategies. Active de-implementation likely entails different dynamics, and unintended consequences, than implementation. VA operational partners in Pharmacy Benefits Management (PBM) Services and the Office of Specialty Care Services (SCS) have helped identify and prioritize an initial set of common clinical practices that should be de-implemented.

Program MyVA Goals: This program will contribute to establishing a culture of continuous performance improvement, and is also designed to scale successful de-implementation initiatives, and grow small wins into big ones.

Program Objectives:

Improve healthcare delivery, safety, and value for Veterans and the VA healthcare system, which are consistent with multiple strategies outlined in the VA Blueprint for Excellence, by working with PBM and SCS partners to de-implement low-value practices. A series of quality-improvement projects will compare the effectiveness of alternative de-implementation strategies that are based on changing clinician information and knowledge, as well as strategies based on providing clinicians with tools and substitutes to the harmful practices. Specific aims are to:

  • Work with key operational leaders to identify and prioritize diagnostics and therapeutics that are ineffective, contraindicated, or of low value to patients -and develop de-implementation strategies that work in concert with operational strategies and policies;
  • Test the effectiveness of de-implementation strategies to reduce ineffective, contraindicated or low-value diagnostics and therapeutics;
  • Develop the science and taxonomy of de-implementation by assessing the impact of de-implementation strategies on clinician professional efficacy and perceptions of the effectiveness of targeted practice and organizational context; and

Assess the budget impact of de-implementation strategies in order to inform dissemination.

Program Methods:

This program will test de-implementation strategies for four clinical practices spanning multiple specialties and patient populations, including therapeutic and diagnostic practices. Each project will test the effectiveness of de-implementation strategies alone and in combination and will assess the budget impact of fielding de-implementation strategies. Projects will assess changes before and after employing de-implementation strategies in participating clinicians' perceptions of the empirical evidence against the ineffective practice; clinicians' intent to reduce the ineffective practice; and professional inefficacy (a component of work-related burnout). Additionally, projects will examine organizational context as a moderator of de-implementation strategy effectiveness across clinical settings and practice changes.

Project Summaries:

Project 1: Test a proactive, pulmonologist-initiated E-consult intervention to de-implement the unnecessary use of inhaled corticosteroids in Veterans with chronic obstructive pulmonary disease (COPD) by having pulmonologists assume more responsibility for supporting COPD patients.

>Project 2: Use two complementary de-implementation strategies—Describe, Investigate, Create, Evaluate (DICE) and Enhanced Academic Detailing—to target clinicians who may over-prescribe antipsychotics in the VA Community Living Centers to Veterans with neuropsychiatric symptoms.

Project 3 (Quality Improvement):Implement arapid-cycle process improvement project, with audit and feedback and blended facilitation (in VISN 20) to improve radiologists' recommendations and to reduce inappropriate further imaging for small, stable nodules in the lungs.