1
|
Chen L, Glatt E, Kerr P, Weng Y, Lough ME. Stir-up Regimen After General Anesthesia in the Postanesthesia Care Unit: A Nurse Led Stepped Wedge Cluster Randomized Control Trial. J Perianesth Nurs 2024; 39:207-217. [PMID: 37978971 DOI: 10.1016/j.jopan.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 06/07/2023] [Accepted: 07/20/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To implement a standardized Stir-up Regimen (deep breathing, coughing, repositioning, mobilization [moving arms/legs], assessing and managing pain and nausea) within the first 30 minutes of arrival in the postanesthesia care unit (PACU), with a goal of decreasing recovery time in the immediate postanesthesia period (Phase I). DESIGN A pragmatic stepped wedge cluster randomized control trial. Initially, data were collected on time in Phase I in three PACUs (control). Subsequently, the same three units were randomized to sequentially transition to the Stir-up Regimen (intervention). METHODS A stepped wedge cluster randomized control trial design was used to implement a standardized Stir-up Regimen in three PACUs in an academic hospital for adult patients who received at least 30 minutes of general anesthesia. The measured outcome was the PACU time in minutes from patient arrival to when the patient met Phase I discharge criteria. Differences between intervention and control groups were evaluated using a generalized mixed-effects model. Nurses were educated about the Stir-up Regimen in team huddles, in-services, video demonstrations, email notifications and reminders, and immediate feedback at the bedside. Implementation science principles were used to assess the adoption of the Stir-up Regimen through a presurvey, postsurvey and spot-check observations in all three PACUs. FINDINGS A total of 5,809 PACU adult patient admissions were included: control group (n = 2,860); intervention group (n = 2,949); males (n = 2,602), and females (n = 3,206). The intervention was associated with a reduction in overall mean Phase I recovery time of 4.9 minutes (95% CI: -8.4 to -1.4, P = .007). One PACU decreased time by 9.6 minutes (95% CI: -15.3 to -4.0, P < .001). The other units also reduced Phase I recovery time, but this did not reach statistical significance. The spot-check observations confirmed the intervention was adopted by the nurses, as most interventions were nurse-initiated versus patient-initiated during the first 30 minutes in PACU. CONCLUSIONS Standardization of a Stir-up Regimen within 30 minutes of patient PACU arrival resulted in decreased Phase I recovery time.
Collapse
Affiliation(s)
- Ling Chen
- Interventional Platform, Stanford Health Care, Stanford, CA.
| | | | - Paul Kerr
- Interventional Platform, Stanford Health Care, Stanford, CA
| | - Yingjie Weng
- Quantitative Sciences Unit, Stanford University, Stanford, CA
| | - Mary E Lough
- Evidence Based Practice Center, Professional Practice and Clinical Improvement, Stanford Health Care, Stanford, CA; Primary Care and Population Health, School of Medicine, Stanford University, Stanford, CA
| |
Collapse
|
2
|
Surr C, Marsden L, Griffiths A, Cox S, Fossey J, Martin A, Prevost AT, Walshe C, Walwyn R. Researchers' experiences of the design and conduct challenges associated with parallel-group cluster-randomised trials and views on a novel open-cohort design. PLoS One 2024; 19:e0297184. [PMID: 38394190 PMCID: PMC10889884 DOI: 10.1371/journal.pone.0297184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 12/29/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Two accepted designs exist for parallel-group cluster-randomised trials (CRTs). Closed-cohort designs follow the same individuals over time with a single recruitment period before randomisation, but face challenges in settings with high attrition. (Repeated) cross-sectional designs recruit at one or more timepoints before and/or after randomisation, collecting data from different individuals present in the cluster at these timepoints, but are unsuitable for assessment of individual change over time. An 'open-cohort' design allows individual follow-up with recruitment before and after cluster-randomisation, but little literature exists on acceptability to inform their use in CRTs. AIM To document the views and experiences of expert trialists to identify: a) Design and conduct challenges with established parallel-group CRT designs,b) Perceptions of potential benefits and barriers to implementation of open-cohort CRTs,c) Methods for minimising, and investigating the impact of, bias in open-cohort CRTs. METHODS Qualitative consultation via two expert workshops including triallists (n = 24) who had worked on CRTs over a range of settings. Workshop transcripts were analysed using Descriptive Thematic Analysis utilising inductive and deductive coding. RESULTS Two central organising concepts were developed. Design and conduct challenges with established CRT designs confirmed that current CRT designs are unable to deal with many of the complex research and intervention circumstances found in some trial settings (e.g. care homes). Perceptions of potential benefits and barriers of open cohort designs included themes on: approaches to recruitment; data collection; analysis; minimising/investigating the impact of bias; and how open-cohort designs might address or present CRT design challenges. Open-cohort designs were felt to provide a solution for some of the challenges current CRT designs present in some settings. CONCLUSIONS Open-cohort CRT designs hold promise for addressing the challenges associated with standard CRT designs. Research is needed to provide clarity around definition and guidance on application.
Collapse
Affiliation(s)
- Claire Surr
- Centre for Dementia Research, Leeds Beckett University, Leeds, United Kingdom
| | - Laura Marsden
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| | - Alys Griffiths
- Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
| | - Sharon Cox
- Department of Behavioural Science and Health, UCL, London, United Kingdom
| | - Jane Fossey
- Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
| | - Adam Martin
- Academic Unit of Health Economics, University of Leeds, Leeds, United Kingdom
| | - A. Toby Prevost
- Nightingale-Saunders Clinical Trials & Epidemiology Unit, Kings College London, London, United Kingdom
| | - Catherine Walshe
- International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | - Rebecca Walwyn
- Clinical Trials Research Unit, University of Leeds, Leeds, United Kingdom
| |
Collapse
|
3
|
Myers LJ, Perkins AJ, Zhang Y, Bravata DM. Identifying transient ischemic attack (TIA) patients at high-risk of adverse outcomes: development and validation of an approach using electronic health record data. BMC Neurol 2022; 22:256. [PMID: 35820867 PMCID: PMC9275263 DOI: 10.1186/s12883-022-02776-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background Risk-stratification tools that have been developed to identify transient ischemic attack (TIA) patients at risk of recurrent vascular events typically include factors which are not readily available in electronic health record systems. Our objective was to evaluate two TIA risk stratification approaches using electronic health record data. Methods Patients with TIA who were cared for in Department of Veterans Affairs hospitals (October 2015—September 2018) were included. The six outcomes were mortality, recurrent ischemic stroke, and the combined endpoint of stroke or death at 90-days and 1-year post-index TIA event. The cohort was split into development and validation samples. We examined the risk stratification of two scores constructed using electronic health record data. The Clinical Assessment Needs (CAN) score is a validated measure of risk of hospitalization or death. The PREVENT score was developed specifically for TIA risk stratification. Results A total of N = 5250 TIA patients were included in the derivation sample and N = 4248 in the validation sample. The PREVENT score had higher c-statistics than the CAN score across all outcomes in both samples. Within the validation sample the c-statistics for the PREVENT score were: 0.847 for 90-day mortality, 0.814 for 1-year mortality, 0.665 for 90-day stroke, and 0.653 for 1-year stroke, 0.699 for 90-day stroke or death, and 0.744 for 1-year stroke or death. The PREVENT score classified patients into categories with extreme nadir and zenith outcome rates. The observed 1-year mortality rate among validation patients was 7.1%; the PREVENT score lowest decile of patients had 0% mortality and the highest decile group had 30.4% mortality. Conclusions The PREVENT score had strong c-statistics for the mortality outcomes and classified patients into distinct risk categories. Learning healthcare systems could implement TIA risk stratification tools within electronic health records to support ongoing quality improvement. Registration ClinicalTrials.gov Identifier: NCT02769338.
Collapse
Affiliation(s)
- Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA. .,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA. .,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA. .,Regenstrief Institute, Indianapolis, IN, USA.
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.,Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.,Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.,VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA.,Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,Regenstrief Institute, Indianapolis, IN, USA.,Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
4
|
Bravata DM, Miech EJ, Myers LJ, Perkins AJ, Zhang Y, Rattray NA, Baird SA, Penney LS, Austin C, Damush TM. The Perils of a "My Work Here is Done" perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack. BMC Health Serv Res 2022; 22:857. [PMID: 35787273 PMCID: PMC9254423 DOI: 10.1186/s12913-022-08207-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/16/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems. METHODS Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015-September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment. RESULTS The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement. CONCLUSIONS Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance. TRIAL REGISTRATION Clinicaltrials.gov ( NCT02769338 ).
Collapse
Affiliation(s)
- Dawn M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
| | - Edward J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Laura J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Anthony J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, Indiana University School of Medicine, IN, Indianapolis, USA
| | - Ying Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nicholas A Rattray
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Sean A Baird
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Lauren S Penney
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Curt Austin
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - Teresa M Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| |
Collapse
|
5
|
Miech EJ, Perkins AJ, Zhang Y, Myers LJ, Sico JJ, Daggy J, Bravata DM. Pairing regression and configurational analysis in health services research: modelling outcomes in an observational cohort using a split-sample design. BMJ Open 2022; 12:e061469. [PMID: 35672067 PMCID: PMC9174826 DOI: 10.1136/bmjopen-2022-061469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Configurational methods are increasingly being used in health services research. OBJECTIVES To use configurational analysis and logistic regression within a single data set to compare results from the two methods. DESIGN Secondary analysis of an observational cohort; a split-sample design involved randomly dividing patients into training and validation samples. PARTICIPANTS AND SETTING Patients who had a transient ischaemic attack (TIA) in US Department of Veterans Affairs hospitals. MEASURES The patient outcome was the combined endpoint of all-cause mortality or recurrent ischaemic stroke within 1 year post-TIA. The quality-of-care outcome was the without-fail rate (proportion of patients who received all processes for which they were eligible, among seven processes). RESULTS For the recurrent stroke or death outcome, configurational analysis yielded a three-pathway model identifying a set of (validation sample) patients where the prevalence was 15.0% (83/552), substantially higher than the overall sample prevalence of 11.0% (relative difference, 36%). The configurational model had a sensitivity (coverage) of 84.7% and specificity of 40.6%. The logistic regression model identified six factors associated with the combined endpoint (c-statistic, 0.632; sensitivity, 63.3%; specificity, 63.1%). None of these factors were elements of the configurational model. For the quality outcome, configurational analysis yielded a single-pathway model identifying a set of (validation sample) patients where the without-fail rate was 64.3% (231/359), nearly twice the overall sample prevalence (33.7%). The configurational model had a sensitivity (coverage) of 77.3% and specificity of 78.2%. The logistic regression model identified seven factors associated with the without-fail rate (c-statistic, 0.822; sensitivity, 80.3%; specificity, 84.2%). Two of these factors were also identified in the configurational analysis. CONCLUSIONS Configurational analysis and logistic regression represent different methods that can enhance our understanding of a data set when paired together. Configurational models optimise sensitivity with relatively few conditions. Logistic regression models discriminate cases from controls and provided inferential relationships between outcomes and independent variables.
Collapse
Affiliation(s)
- Edward J Miech
- Quality Enhancement Research Initiative (QUERI) and Health Services Research and Development (HSR&D), Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Anthony J Perkins
- Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ying Zhang
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Laura J Myers
- Quality Enhancement Research Initiative (QUERI) and Health Services Research and Development (HSR&D), Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Jason J Sico
- Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanne Daggy
- Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dawn M Bravata
- Quality Enhancement Research Initiative (QUERI) and Health Services Research and Development (HSR&D), Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| |
Collapse
|
6
|
Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack. J Gen Intern Med 2021; 36:322-332. [PMID: 33145694 PMCID: PMC7878645 DOI: 10.1007/s11606-020-06100-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 07/30/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). OBJECTIVE We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). DESIGN A stepped-wedge implementation trial with six geographically diverse sites. PARTICIPANTS The six facility QI teams were multi-disciplinary, clinical staff. INTERVENTIONS PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. MAIN MEASURES Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. KEY RESULTS Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. CONCLUSIONS The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system. TRIAL REGISTRATION clinicaltrials.gov: NCT02769338.
Collapse
|
7
|
Bravata DM, Myers LJ, Perkins AJ, Zhang Y, Miech EJ, Rattray NA, Penney LS, Levine D, Sico JJ, Cheng EM, Damush TM. Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack: A Nonrandomized Cluster Trial. JAMA Netw Open 2020; 3:e2015920. [PMID: 32897372 PMCID: PMC7489850 DOI: 10.1001/jamanetworkopen.2020.15920] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist. OBJECTIVE To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA. INTERVENTION The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. MAIN OUTCOMES AND MEASURES The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period. RESULTS Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008). CONCLUSIONS AND RELEVANCE The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02769338.
Collapse
Affiliation(s)
- Dawn M. Bravata
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Department of Neurology, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Laura J. Myers
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Anthony J. Perkins
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Ying Zhang
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- now with Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha
| | - Edward J. Miech
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| | - Nicholas A. Rattray
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Lauren S. Penney
- South Texas Veterans Health Care System, San Antonio
- Department of Medicine, University of Texas Health, San Antonio
| | - Deborah Levine
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Jason J. Sico
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven
- VA Neurology Service, VA Connecticut Healthcare System, West Haven
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale University School of Medicine, New Haven, Connecticut
| | - Eric M. Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
| | - Teresa M. Damush
- Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana
- Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis
- Regenstrief Institute, Indianapolis, Indiana
| |
Collapse
|
8
|
Bravata DM, Myers LJ, Homoya B, Miech EJ, Rattray NA, Perkins AJ, Zhang Y, Ferguson J, Myers J, Cheatham AJ, Murphy L, Giacherio B, Kumar M, Cheng E, Levine DA, Sico JJ, Ward MJ, Damush TM. The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods. BMC Neurol 2019; 19:294. [PMID: 31747879 PMCID: PMC6865042 DOI: 10.1186/s12883-019-1517-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/28/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles. METHODS This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability. DISCUSSION PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines. TRIAL REGISTRATION clinicaltrials.gov: NCT02769338 [May 11, 2016].
Collapse
Affiliation(s)
- D M Bravata
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA.
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA.
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA.
- Regenstrief Institute, Indianapolis, IN, USA.
| | - L J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - B Homoya
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - E J Miech
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - N A Rattray
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - A J Perkins
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Y Zhang
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - J Ferguson
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - J Myers
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - A J Cheatham
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - L Murphy
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
| | - B Giacherio
- Office of Healthcare Transformation (OHT), Veterans Health Administration (VHA), Washington, DC, USA
| | - M Kumar
- Office of Healthcare Transformation (OHT), Veterans Health Administration (VHA), Washington, DC, USA
| | - E Cheng
- Department of Neurology, VA Greater Los Angeles Healthcare System, California, Los Angeles, USA
- Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles, California, Los Angeles, USA
| | - D A Levine
- Department of Internal Medicine and Neurology and Institute for Health Policy and Innovation, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - J J Sico
- Clinical Epidemiology Research Center and Neurology Service, VA Connecticut Healthcare System, West Haven, CT, USA
- Departments of Internal Medicine and Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - M J Ward
- VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - T M Damush
- Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, USA
- VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN, 46202, USA
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| |
Collapse
|