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QUERI Helps VA Optimize Healthcare During Pandemic

Takeaway: With a flexible structure including implementation and data science expertise, QUERI Centers are designed to adapt their current implementation efforts and support VA in responding to emerging issues, like COVID-19, using evidence-based practices (EBPs), collaborative team-based approaches, and implementation strategies to support more rapid provider uptake of high-quality care.

The unprecedented Coronavirus disease 2019 (COVID-19) pandemic has led to a significant shift in U.S. healthcare. Like other health systems, VA is primarily focused on the prevention, containment, and treatment of COVID-19. However, the VA healthcare system also must continue to care for Veterans with an array of medical and mental health conditions. For example, a recent study indicates hypertension, diabetes, and obesity are linked to poorer outcomes among those who contract COVID-19,¹ and these conditions are highly prevalent among Veterans: approximately 68% of Veterans are considered either overweight or obese;² nearly 25% have diabetes;³ and hypertension is the most common chronic condition among Veterans, affecting 37% of VA patients.⁴ Those with compromised immune systems also are at greater risk from COVID-19, and VA is the largest provider of HIV care in the country. Moreover, QUERI helped lead the country in rapid testing efforts for HIV.⁵

The pressing need for a rapid scalable response to this highly contagious disease highlights the important role of implementation strategies in ensuring the widespread, consistent uptake of best practices among frontline providers, who also must treat ongoing chronic conditions. With a flexible structure including implementation and data science expertise, QUERI Centers are designed to adapt their current implementation efforts and support VA in responding to emerging issues, like COVID-19, using evidence-based practices (EBPs) and collaborative team-based approaches.

QUERI COVID-19 Survey

QUERI leadership is currently conducting a QUERI COVID-19 Survey to assess the needs of QUERI investigators who are responding to the needs of operations partners, VA leadership, and clinicians. Following are some of the early survey findings.

QUERI stakeholders, including frontline clinicians and various operations partners, faced the following challenges due to the COVID-19 outbreak:

• Operations partners needing to shift focus from implementing current EBPs to focusing on supporting COVID-19 clinical priorities;
• Providers needing to switch from delivering EBP to focusing on COVID-19-related services; and
• Providers needing to deliver best practices virtually, maximizing telehealth resource use.

QUERI has several centers, programs, and projects devoted to virtual healthcare, including the Virtual Specialty Care QUERI Program, eHealth QUERI, Enhancing Veterans’ Access to Care through Video Telehealth Tablets, Telewound Practice Partnered Evaluation Initiative, Making Medication-Assisted Treatment Available at CBOCs Using Telemedicine, and Expanding TelePain across VISN 20.

QUERI investigators are working closely with VA leadership to combat these challenges by:

• Adapting EBPs for virtual or home delivery, including offering virtual implementation support and resources;
• Providing virtual implementation support (e.g., facilitation) to providers to support EBP uptake;
• Expanding the implementation of best practices to new patient populations or sites;
• Adjusting EBPs to meet the needs of individual medical facilities;
• Leveraging data infrastructure to evaluate COVID-19 related outcomes and infection risk;
• Assessing how COVID-19 is affecting Veterans; and
• Providing support with COVID-19 related stress.

Helping Veterans deal with the added stress of the pandemic is particularly important, considering the prevalence of PTSD, general anxiety disorders, and depression among VA’s patient population.

In addition, QUERI investigators have been making the following changes in their strategy to ascertain crucial data:

• Adding a risk factor screening/assessment related to COVID-19;
• Switching the data collection modality (e.g. virtual, email, mail format); and
• Using more pre-existing data.

For example, Precision Monitoring to Transform Care (PRISM) QUERI is utilizing its extensive experience with medical record and VA national data to evaluate the potential association between ACE-inhibitor and angiotensin receptor blocker (medications to treat heart disease and hypertension) use and health outcomes. Investigators also will describe COVID-19 outcomes among Veterans and examine relationships between therapeutic agents and outcomes. A key element of this study is the use of chart review to validate and augment data obtained from electronic health record sources. The QUERI team is working with Indianapolis VAMC (Veteran Health Indiana) leadership to describe the characteristics and outcomes among Veterans with COVID-19 at that facility – and to identify any potential toxicities from novel therapeutic agents to inform care.

During this global health crisis, all QUERI investigators will use their unique skill sets to help VA continue to provide optimal care to our nation’s Veterans.

1. Richardson S, Hirsch J, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5,700 patients hospitalized with COVID-19 in the New York City area. JAMA. April 22, 2020.
2. Maciejewski M. Measuring the longitudinal relationships between obesity, weight management intervention, and medical expenditure. HSR&D study IIR 18-019.
3. Prevalence of and trends in diabetes among Veterans, United States, 2005-2014. CDC, Research Brief (14). December 14, 2017.
4. Mohanty A. Race/ethnic differences in guideline recommended hypertension medications in VHA. HSR&D study CDA 18-327.
5. HIV Oral Rapid Test Implementation Toolkit.