QUERI Center Updates
Chronic Heart Failure
Ischemic Heart Disease
Polytrauma and Blast-Related Injuries
Spinal Cord Injury
Substance Use Disorder
Chronic Heart Failure
Using Facility Teams to Reduce Readmissions for Veterans with Heart Failure
A goal of the Chronic Heart Failure Quality Enhancement Research Initiative (CHF-QUERI) is to reduce
unnecessary care while increasing guideline-recommended care for Veterans with heart failure. For this purpose, it formed a multi-level and
multi-disciplinary social network called the Heart Failure (HF) Provider Network with VA
providers at all the VA facilities. Many VA facilities have teams devoted to preventing readmissions for heart failure. These teams almost
always include physicians in addition to nurses, advanced practice nurses, physician assistants, QI/quality management staff, pharmacists, and facility
leadership. Also, these facilities often participate in multiple national initiatives to improve their goal of reducing readmissions, including H2H, Project RED (Re-Engineered Discharge Training Program, Transitional Care
Model (TCM), and other local or regional collaboratives.
For more information, please contact Paul Heidenreich, M.D., M.S., at Paul.Heidenreich@va.gov, or Anju Sahay,
Ph.D., at Anju.Sahay@va.gov.
Roles and Impacts of Local Performance Measure Implementation Strategies
Clinical performance measurement has been a key element in transforming care delivery within the VA healthcare system. However, there are a number of signs
that current performance measurement systems used within and outside VA may be reaching the point of maximum benefit to care and, in some settings, may be
resulting in negative consequences to care that can include overtreatment and diminished attention to patients' needs and preferences. Diabetes-QUERI has been involved in a long-standing partnership with VA's Office of Informatics and
Analytics (OIA) to develop strategies to mitigate unintended consequences of performance measurement.
DM-QUERI recently completed a rapid response study (RRP 11-420)
to understand how diabetes performance measures are implemented and the pathways through which management decisions about implementing measures affect
day-to-day clinical practice. In this study, investigators conducted interviews with 63 network- and facility-level executives, managers, and frontline
providers and staff from four VA facilities in four separate VISNs. They then identified several ways in which local implementation strategies impact
providers' responses to performance measures, which can undermine the provision of high-quality, patient-centered care. These strategies include:
Feedback reports to providers that are focused on performance gaps and dissociated from providers' capabilities to address them;
Evaluative criteria, reinforced by clinical reminders triggered in the electronic medical record during patient encounter, that are at odds with
patient-centered care; and
Pressure created by an environment, reinforced by performance-based bonuses, that is viewed as more punitive than motivating.
From these findings, investigators identified the need to work with VA system leaders to develop new measures that are patient-centered and clinically
meaningful–and to test implementation strategies that ensure positive motivational responses by local managers and frontline providers.
For more information, please contact Laura Damschroder, M.S., M.P.H., at Laura.Damschroder@va.gov.
How Sharing Clinical Notes Impacts Providers and Patients
Clinical notes (e.g., outpatient clinic visits, discharge summaries) are now available via VA's Blue Button (via My HealtheVet) and through VA Mobile Health Apps.
In the Open Notes Evaluation project, investigators with VA/HSR&D's eHealth Quality Enhancement Research Initiative ( eHealth-QUERI) will examine the influence of sharing clinical notes on healthcare
processes and outcomes, including how communication between providers and Veterans may change as a result of clinical note availability. Using the database
developed by eHealth- QUERI, investigators will examine the characteristics of Veterans that view their notes and those who do not. They will then examine
administrative data to determine changes in patient-clinic communication through secure messaging and utilization of healthcare services. For a sample of
providers, investigators also will conduct a chart review, looking for provider documentation changes in Veterans who have looked at their notes and
communicated back to the providers. Chart abstractions will be performed for two visits prior to notes access and will continue through six months of
access to notes.
For more information, please contact Thomas Houston, M.D., MP.H., F.A.C.M.I., at Thomas.Houston2@va.gov.
Linking Veterans with Newly Diagnosed HIV to Appropriate Care
A primary goal for VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative ( HH-QUERI) is to increase Veterans' access to HIV testing and, if positive, to increase
access and linkage to appropriate care. In collaboration with VA's Clinical Public Health program office, projects conducted by HH-QUERI
have contributed to substantial increases in the rates of HIV testing within the VA. However, it is not known whether expanded HIV testing identifies
Veterans with previously unknown HIV infection and, even more crucially, whether newly diagnosed patients are being promptly linked to appropriate medical
Dr. Matthew Goetz, HH-QUERI Clinical Coordinator, led a study
that developed an algorithm to identify HIV patients who were newly diagnosed with HIV infection within the VA healthcare system. Using this algorithm,1 investigators are now evaluating the rates of new diagnoses at facilities that participated in the suite of HIV testing programs.
Preliminary results indicate that during the risk-based testing period (i.e., prior to mid-2009), 0.46% of Veterans tested for HIV for the first time were
found to be infected. During the subsequent period, when once per lifetime HIV testing was routinely recommended for all VA patients, the frequency of new
diagnoses decreased to 0.14%. Overall, 1.29% and 0.44% of all first HIV tests were positive in the risk-based and routine testing periods, respectively. In
ongoing work, the age, race/ethnicity distributions of newly diagnosed Veterans are being assessed, as are the patient- and facility-level variations of
the timeliness with which linkage to HIV care is achieved.
For more information, please contact Matthew Goetz, M.D., at Matthew.Goetz@va.gov.
1. Goetz M, Hoang T, Kan V, et al.
Development and validation of an algorithm to identify patients newly diagnosed with HIV Infection from electronic health records. AIDS Research and Human Retroviruses. March 20, 2014;Epub ahead of print.
Ischemic Heart Disease
Data Resource on VA Quality of Care for Acute Coronary Syndrome
In collaboration with VA Operational partners, including the National Program Director for Cardiology, John Rumsfeld, M.D., Ph.D., and the Director of
Office of Analytics and Business Intelligence (OABI), Stephan Fihn, M.D., M.P.H., VA/HSR&D's Ischemic Heart Disease Quality Enhancement Research
Initiative (IHD-QUERI) has created an "operational" data resource to answer questions about
the quality of care for Veterans having acute coronary syndrome (ACS) in a timely manner.
Called ACS Care Quality Assessment (ACQuA), the new QI database leverages IHD-QUERI's experience combining data abstracted from patient records with VA
administrative data to create a unique longitudinal dataset. Since 2005, IHD-QUERI has maintained and updated a VA research repository called the Cardiac
Care Clinical Follow up Study (CCFCS), which has been used to
support IRB-approved research protocols–and has produced many publications that identified gaps in care and adverse drug interactions. However, because
CCFCS is a research repository, IHD-QUERI investigators were unable to use it when responding to queries from operational partners that had questions about
the quality of VA care for Veterans with acute myocardial infarction. IHD-QUERI will continue to maintain CCFCS to support approved research projects,
while developing the ACQuA data resource for operational inquiries.
In the next year, IHD-QUERI investigators also will work to augment ACQuA with data from VA's Clinical Assessment Reporting and Tracking (CART) program and the Centers for Medicare & Medicaid Services in order
to expand performance metrics that are used to assess and develop quality reports for individual hospitals. In addition, ACQuA will provide opportunities
to provide feedback to VA sites and identify gaps in care that may lead to larger research opportunities.
For more information, please contact G. Blake Wood, M.S., at Gordon.Wood@va.gov or Michael Ho, M.D., Ph.D., at Michael.Ho@va.gov.
Partnering with VA Operational Leaders to Transfer an Implementation Strategy
The Mental Health Quality Enhancement Research Initiative (MH-QUERI) recently completed a
study of an external/internal implementation facilitation (IF) strategy. The study was conducted within the context of VA's policy to implement Primary
Care-Mental Health Integration. Based on early successes, VA Office of Mental Health Operations (OMHO) engaged MH-QUERI in a partnership to integrate this
strategy into OMHO's efforts to support national implementation of the VA Uniform Mental Health Services Handbook. In this partnership, researchers turned
generalizable lessons from implementation research into actionable guidance for use by clinical managers. Two recent Psychiatric Services columns
describe this partnership and the lessons researchers and operational leaders learned.
Research and Services Partnerships: Responding to Needs of Clinical Operations Partners: Transferring Implementation Facilitation Knowledge and Skills
describes the IF strategy, the initiation of the partnership, and the development of a training manual, "
Implementation Facilitation Training Manual: Using External and Internal Facilitation to Improve Care in the Veterans Health Administration
." The column also describes and links to the manual, which was one component of a training program designed by the partners to meet OMHO needs.
Research & Services Partnerships: Lessons Learned Through a National Partnership Between Clinical Leaders and Researchers
describes "partnering pearls" identified by MH-QUERI researchers and clinical operations managers, while they were engaged in this unique partnership. The
lessons learned are reflections about the necessary foundations for successful partnerships and the importance of developing relationships, communicating
regularly, and recognizing and adapting to partners' timelines and time constraints.
For more information, please contact Mona Ritchie, Ph.D. Candidate, at Mona.Ritchie@va.gov.
Polytrauma and Blast-Related Injuries
Supported Employment for Veterans with TBI
More than 20,000 Iraq and Afghanistan War Veterans experiencing traumatic brain injury (TBI)-related sequelae are cared for by the VA each year, many in
the Polytrauma/TBI System of Care. Unemployment rates are high among civilians with TBI and may be even higher
among Veterans with TBI given common co-occurring mental and physical health conditions. Supported Employment ( SE), an evidence-based vocational rehabilitation program, is currently available to
Veterans with serious mental illness and could potentially be extended to Veterans in the TBI/Polytrauma System of Care. SE is intensive relative to other
vocational services and may not be the right-sized intervention for all Veterans with TBI. Thus, researchers with the Polytrauma and Brain-Related Injuries
Quality Enhancement Research Initiative (PT/BRI-QUERI) are conducting a study to examine
the needs for, and interests in vocational rehabilitation services, as well as the acceptability of SE among Veterans with mild versus moderate or severe
This project began in January 2014 and involves a survey of 1,800 randomly sampled Iraq and Afghanistan War Veterans across the U.S., who incurred one or
more TBIs during deployment–and who use VA healthcare services. In the survey, Veterans will be asked about their employment history, knowledge and
receipt of vocational services, and perceived ability to access and utilize SE. Responses will be compared by Veterans' TBI severity level and
comorbidities. Knowledge from this project will help identify the level of need in Veterans with TBI, and will inform VA program offices about the possible
expansion of SE to this patient population.
For more information, please contact Kathleen Carlson, Ph.D., at Kathleen.Carlson@va.gov.
Implementation of Clinical Video Telehealth for TBI Evaluations
To identify Veterans with traumatic brain injury (TBI) who may benefit from treatment and services, VA implemented a national clinical reminder. Veterans
who have a positive screen are then referred for a Comprehensive TBI Evaluation (CTBIE). Despite these referrals, recent data suggests that many Veterans
do not have a CTBIE to determine a diagnosis and develop a plan to treat symptoms. To increase access to CTBIEs, VA's Office of Physical Medicine and
Rehabilitation (PM&R) set up a number of facilities as pilot locations for administering the CTBIE using clinical video telehealth (CVT).
Working with PM&R and PT/BRI-QUERI, Dr. Smith and colleagues recently completed a study to characterize the implementation of CVT to provide
CTBIEs. Findings show that barriers to implementing CVT for TBI screening and management included challenges with scheduling
(e.g., coordinating the schedules between two different sites), equipment issues, and conducting a physical exam over a virtual modality. Strategies used
to enhance implementation included establishing good relationships and communication with staff, making a personal connection, and establishing rapport
with Veterans via CVT, in addition to providing accessible resources to both patients and providers. Moreover, providers' responses indicated that there
are far more advantages to utilizing CVT—including travel convenience, cost-effectiveness, and patient satisfaction—than there are disadvantages (e.g.,
limitations in assessing comorbid conditions besides TBI). Researchers are currently preparing the results for publication.
For more information, please contact Bridget Smith, Ph.D., at Bridget.Smith@va.gov.
Concussion Coach: VA's Self-Management Smart Phone Application
"Smart phone" mobile applications have become a primary source of information and communication among large percentages of Americans, especially those of
the OIF/OEF/OND generation. The VA has been at the forefront of finding new and creative ways to reach Veterans using technology, such as My HealtheVet, telehealth, mobile medical clinics, and most recently, "smart phone"
technology. VA has more than 15 mobile apps in various stages of development to assist Veterans and their
families with issues ranging from mild TBI to parenting. Key factors integrated into these mobile technologies include accessibility, convenience,
self-management, and reminder cues.
The primary goal of the proposed study, funded through HSR&D, is to evaluate the efficacy of VA's self-management smart phone application, "Concussion Coach," for improving clinical outcomes in those with a history of mild traumatic brain injury and to determine what aspects of Concussion Coach are most useful to Veterans. Conducted with investigators from PT/BRI-QUERI, this research also is expected to improve access among Veterans
with mild TBI who still have symptoms months to years after injury. In addition, the information obtained will inform strategies to improve the application
of smart phone technology and enhance its use among Veterans–and inform the rollout of other smart phone applications.
For more information on this project, please contact Heather Belanger, Ph.D., at Heather.Belanger@va.gov .
Spinal Cord Injury
Enhancing Implementation of Telehealth for Veterans with SCI/D
Veterans with spinal cord injuries and disorders (SCI/D) often have significant mobility limitations that create challenges for accessing health care.
Additionally, some Veterans with SCI/D live in areas that require them to travel substantial distances to the nearest SCI center. Clinical video telehealth
(CVT) programs have been implemented to allow Veterans to access services in their home and at local VA facilities that do not have an SCI Center.
To examine the factors related to the implementation of CVT for Veterans with SCI/D, investigators with VA/HSR&D's Spinal Cord Injury Quality
Enhancement Research Initiative (SCI-QUERI) are currently conducting semi-structured
interviews with healthcare providers (physicians, nurses, and social workers) at SCI spoke sites and Community-Based Outpatient Clinics (CBOC). The
objectives of these interviews are to identify: 1) approaches to using CVT; 2) barriers, facilitators, and best practices with implementing CVT; and 3)
potential strategies to enhance implementation of CVT. To date, a total of 23 providers have agreed to participate. Data collection and analysis of the
interview data is in progress.
Along with the interview, participants filled out a brief questionnaire. Initial responses indicate that most common applications of CVT for Veterans with
SCI/D include discharge planning, wound management, post-discharge follow-up, and rehabilitation therapy. Study participants also are identifying barriers
to the use of CVT and the strategies they are using to facilitate CVT use. The results of this project will inform meetings with key stakeholders to
develop strategies to enhance implementation of CVT, and to increase access to care for Veterans with SCI/D.
For more information, please contact Rachael MartÃnez, Ph.D., at Rachael.N.Martinez@va.gov, or Bridget
Smith, Ph.D., at Bridget.Smith@va.gov.
Risk-Adjusted Mortality and Readmissions among Veterans with Stroke
The Centers for Medicare & Medicaid Services (CMS) will publicly report 30-day risk-standardized mortality rates (RSMRs) and risk-standardized
readmission rates (RSRRs) for hospitalized stroke patients in 2014. However, to date there has been scant reporting of hospital-level variation in
risk-adjusted outcomes for Veterans with stroke.
Using VA data, investigators with VA/HSR&D's Stroke Quality Enhancement Research Initiative ( Stroke-QUERI) identified Veterans hospitalized for stroke in FY2009-2011, as well rates of
all-cause readmission and mortality.
Over the study period, there were 8,671 stroke admissions at 123 VA hospitals among Veterans ages 65 and older. The mean 30-day mortality and readmission
rates were 9% and 15%, respectively. The mean facility-level RSMR was 9% (range 6% to 16%), and the mean RSRR was 15% (range 13% to 18%). Applying CMS
methodology to VA hospitals permits comparison of facility-level mortality and readmission rates; however, because the stroke volume at each VA facility is
relatively small, and because there was little facility-level variation in RSMRs and RSRRs, it is difficult to distinguish performance of VA facilities.
Notably, risk-standardized mortality rates were significantly lower in the VA as compared to CMS (9% vs. 16%). Additional research is required to identify
factors that may contribute to lower mortality rates among Veterans with stroke.
For more information, please contact Laura Myers, Ph.D., at Laura.Myers2@va.gov
Substance Use Disorder
Implementing Tobacco Treatment in SUD Residential Treatment Programs
Although smoking among Veterans enrolled in VA healthcare has declined from 33% in 1999 to 20% in 2011, individuals with substance use disorder (SUD) are
three to four times more likely to have concurrent nicotine dependence, and significantly more likely to suffer death and illness from tobacco use than
from other addictions. Recent evidence indicates that integrating tobacco treatment into SUD specialty care does not interfere with the recovery process
and may improve long-term abstinence; yet, tobacco treatment has not been widely implemented within VHA addiction treatment programs.
VA's Office of Tobacco & Health Policy & Programs works to improve access
to evidence-based tobacco treatment for Veterans with mental health and substance use disorders. In partnership with this Office, VA's Mental Health
Services and the Office of Mental Health Operations, researchers with VA/HSR&D's Substance Use Disorder Quality Enhancement Research Initiative ( SUD-QUERI) have:
Documented the prevalence of tobacco use among Veterans in Substance Abuse Residential Rehabilitation Treatment Programs (SARRTPs; 79%);
Documented significant variability and gaps in care;
Identified barriers and facilitators to implementing tobacco treatment within these settings;
Developed a toolkit for SUD residential treatment programs and staff; and
Contributed to Tobacco & Health Policy & Programs' National Training Meeting "Increasing Access to Smoking Cessation Treatment for Veterans with
Mental Health and Substance Use Disorders."
A new study will evaluate whether external and internal facilitation can improve implementation of pharmacotherapy for tobacco dependence within SARRTPs.
For more information, please contact Elizabeth Gifford, Ph.D., at Elizabeth.Gifford@va.gov.