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Using QUERI & Using QUERI & Implementation Science Implementation Science
Theories and Theories and Frameworks to Improve Frameworks to Improve
Access and EquityAccess and EquityS. Randal Henry, DPH, MPH
QUERI HIV/Hepatitis C
PrefacePreface
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Overview Overview
1. Does implementation of disparities reduction programs differ from general quality improvement interventions?
2. How can implementation science contribute to disparities reduction research?
3. How can collaboration and partnership-building contribute to the reduction of health disparities?
4. How can we develop and implement programs that address the need for comprehensive, integrated care for patients with multiple co-morbid conditions that require care across multiple services lines?
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The VA Healthcare System: The VA Healthcare System: An Ideal Environment for Disparities An Ideal Environment for Disparities
ResearchResearch Patients are racially and ethnically diverse and
many are economically disadvantaged Access to healthcare is similar across veteran
populations, eliminating this key reason for disparities in health care
Computerized clinical and administrative national databases on veterans served
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VA HSR&D and Disparities VA HSR&D and Disparities ResearchResearch
The VA supports disparities research Improving access to care and reducing health
disparities is a priority research focus Established the Center for Health Equity Research
and Promotion (CHERP) and Center for Disease Prevention and Health Interventions for Diverse Populations
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Poll QuestionPoll Question
Does the implementation of access and equity improvement interventions differ from general quality improvement (QI) interventions?
Yes No
Cyber Seminar Cyber Seminar GoalsGoals
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CyberSeminar GoalsCyberSeminar Goals
Encourage the quality improvement community to address impaired access and inequitable distribution of care
Encourage the access and equity community to utilize implementation research
Promote the use of implementation science to reduce health disparities
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Introduction:Introduction:
The VA is committed to delivering high quality
healthcare care in an equitable manner.
What are Health What are Health Disparities?Disparities?
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Health disparities are Health disparities are differences…differences…
in the quantity and quality of healthcare provision
in the prevalence, mortality, and burden of disease and other adverse health conditions
not due to access related factors, clinical need, preferences, or appropriateness of the intervention (IOM)
Poll QuestionPoll Question
In the course of your research or clinical practice, have you identified a health disparity?
Yes?
No?
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Evidence of disparitiesEvidence of disparities
Evidence of racial and ethnic disparities in health care is consistent across a range of illnesses and healthcare services. (Smedley et
al)
Disparities have been demonstrated in the Veterans Affairs (VA) healthcare system.
Smedley B, Stith A, & Nelson AR.Unequal treatment confronting racial and ethnic disparities in healthcare. City: National Academies Press (US), 2003.
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Inequities within the VAInequities within the VA Associated with
age, gender, race/ethnicity and income:
More consistently observed for processes that:
entail more risk and require more intensive decision making & communication
require more effort on the part of patients and/or providers
medication adherence
Associated with geographic location: When compared to their urban
counterparts, rural veterans have; worse health-related quality-of-
life report less access to care use fewer healthcare services are more dependent on the VA
for their healthcare services travel burden to specialty
services is substantially greater research on rural veterans health
and health care is lacking.
Saha S, Freeman M, Toure J, et al. Racial and ethnic disparities in the VA healthcare system: a systematic review. 2007 Jun. Department of Veterans Affairs HSR&D
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Vulnerable Patient Vulnerable Patient GroupsGroups
Racial/ethnic minorities Women Homeless Elderly Low socioeconomic status Stigmatizing medical or psychiatric illness Diminished autonomy
Disparities by Disparities by QUERI QUERI
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Disparities By Clinical Disparities By Clinical Content AreaContent Area
Disparities
Clinical Content Area QUERI Group Present Not Present
Arthritis/pain management 6 1
Cancer treatment 2 2
Diabetes Diabetes Mellitus 7 2
Heart and vascular disease Chronic Heart Failure and Ischemic Heart
Disease
20 10
HIV/Hepatitis C HIV/Hepatitis 4 3
Mental health/substanceabuse
Mental Health and Substance Use
Disorders
11 10
Preventive/ambulatory care 8 4
Rehabilitation and palliativecare
Polytrauma and Blast Related Injuries
2 2
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Utilization or Outcome Measure DisparitiesPresent
DisparitiesNot Present
Surgery and invasive procedures 21 11
Medication Use Prescribing Adherence
95
70
Basic services/processes of care* 13 10
Referral 1 2
Patient satisfaction 2 3
Intermediate outcomes** 5 1
Saha S, Freeman M, Toure J, Tippens K, Weeks C. HSR&D Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review (2007)
*E.g.: lab tests, outpatient visits
**E.g.: control of blood pressure, blood glucose, lipids
Disparities By Disparities By Utilization/Outcome Utilization/Outcome
MeasureMeasure
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Polling Questions #2Polling Questions #2
What is the key barrier to improving access and equity for veterans?
1. Individual/patient-level factors
2. Organizational/institutional factors
Which VA Programs Which VA Programs Address Access and Address Access and
Equity?Equity?
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The VA may be able to address individual and institutional barriers to care
A greater understanding of the prevalence and influence of these processes is needed and should be sought through research
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Center for Health Equity Center for Health Equity Research and Promotion Research and Promotion
(CHERP)(CHERP) HSR&D Center of Excellence
Promote equity and quality in health and health care
A collaboration among key entities within VISN4 Investigators played key roles in the development
of Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review
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VA Center for Minority VA Center for Minority VeteransVeterans
Goals Provide and promote the use of VA
programs, benefits, and services use by minority veterans
Make benefits and services more accessible to minority veterans
Evaluate current programs and make recommendations on how VA can better serve minority veterans
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Office of Quality and Office of Quality and Performance (OQP)Performance (OQP)
Operational focus on disparities Race/ethnicity Gender
OQP custodian of rich source of data for health disparities research OQP Chronic pain (race) Alcohol Counseling (race) Immunization (gender) Quality of Care (mental health, MS, SCI, Chronic illness,
rural/urban)
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Poll QuestionPoll Question
What do you think is the major barrier to addressing disparities? Documenting/diagnosing/identifying
organizational factors that contribute to disparities Designing/delivering disparities reduction
programs Creating policy changes Overcoming organizational barriers
What is Implementation Science?
How can it help reduce identified health disparities?
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Implementation Science Implementation Science (IS)(IS)
Implementation Science is the study of the systematic uptake of knowledge and the implementation of that knowledge into routine organizational practice (and everything that facilitates or impedes it)
Typically conducted in health services settings Includes examination of the influence of contextual factors
(e.g. organizational policy) and individual factors (e.g. healthcare professionals) on organizational behavior
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Implementation Science Implementation Science can…can…
Develop standards for evaluating access and equity
Generate new insights and generalizable knowledge regarding dissemination / implementation of disparities reduction
Develop, test and refine disparities reduction theories, hypotheses, models and principles
Determine the relative effect of quality improvement interventions among patients at highest risk for impaired access and inequitable care
Four Implementation Science Frameworks that can be used to
Assess Access and Equity
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CHERP Conceptual CHERP Conceptual Model for Health Model for Health
Disparities ResearchDisparities ResearchFirst Generation Detect disparities in
health or health care
Second Generation
Third Generation
Understand reasons for disparities
Develop interventions to eliminate disparities
Kilbourne et al. American Journal of Public Health, December 2006
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Behavioral Model of Behavioral Model of VulnerabilityVulnerability
Chart Adapted from: Gelberg, L, Andersen RM, and Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people (2000)
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SuccessfulImplementation
= f (E, C, F)
Evidence= Research; Clinical experience;
Patient experience; & Local knowledge
Context= Receptive context; Culture;
Leadership; & Evaluation
Facilitation= Purpose; Role; Skill & Attributes
PARIHS FrameworkPARIHS Framework
PRECEDE PROCEED PRECEDE PROCEED FrameworkFramework
Phase 5 Administration and Policy Diagnosis
Phase 4 Educational and Organizational Diagnosis
Phase 3 Behavioral and Environmental Diagnosis
Phase 2 Epidemiological Diagnosis
Phase 1 Social Diagnosis
Health Promotio
n
Phase 6 Implementation
Phase 7 Process Evaluation
Phase 8 Impact Evaluation
Phase 9 Outcome Evaluation
Health education
Policy regulation organization
Predisposing factors
Reinforcing factors
Enabling factors
Behavior and Lifestyle
Environment
HealthQuality of Life
PRECEDEPRECEDE
PROCEEDPROCEED
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Polling Questions # 3Polling Questions # 3
What is the key barrier to Quality Improvement (QI) in medical care delivery?
1. Individual factors
2. Societal Factors
3. VA related organizational/institutional factors
IV. Utilizing the QUERI IV. Utilizing the QUERI Model to Improve Model to Improve Access and EquityAccess and Equity
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QUERI MissionQUERI Mission
Enhance the quality and outcomes of VA health care by systematically implementing clinical research findings and evidence-based recommendations into routine clinical practice. practice needs determine the research agenda research results determine interventions that
improve the quality of patient care.
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QUERI Four-Phase QUERI Four-Phase Implementation Research Implementation Research
FrameworkFramework
Phase Study Type Form of Evaluation
Pre-trial Program Conceptual design of implementation program and underlying design (logic) model from theory, prior empirical research
Phase 1 Pilot / Pilot test, assess feasibility, formative evaluation and refinement,Formative develop intervention/evaluation protocols
Phase 2 Efficacy Small-scale rigorous trial in controlled settings with ongoingintervention support; emphasis on internal validity
Phase 3 Effectiveness Large-scale rigorous trial under routine conditions in variedsettings; emphasis on external validity
Phase 4 Monitoring Ongoing monitoring and feedback
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The The ClassicClassic Six-Step Six-Step QUERI ProcessQUERI Process
1. Identify high risk/high burden conditions
2. Identify best practices
3. Define existing practice patterns in VA and variations from best practices
4. Identify (or develop) and implement programs to promote best practices
5. Document outcome and system improvements
6. Document improvements in health-related quality of life
V. Next StepsV. Next Steps
Using Implementation Science to Study and Promote Equity
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Future Directions for VA Future Directions for VA Disparities ResearchDisparities Research
Leading investigations to better understand the patient, provider, and system level causes of health disparities
Developing and evaluating new interventions to reduce health disparities
Improve the quality and equity of VA health care through effective collaborations and dissemination of research findings
Ensuring that health care equity is considered an integral component of health care quality in VA
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PollPoll
What is the best method to improve the overall health status of all veterans? Develop specific programs for the most vulnerable
(high-risk) patient groups Develop universal interventions (designed to
improve the health of all)
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SummarySummary
The VA is an ideal setting to conduct first, second, and third generation disparities research
The VA HSR&D is committed to supporting this line of investigation and to training the next generation of disparities researchers
The VA is a national leader in advancing the field of disparities research, generating findings highly relevant to other health care systems
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VA HSR&D
CHERP
VA CIPRS
VA QUERI (esp. HIV/Hepatitis C)
OQP
Acknowledgements Acknowledgements