VA Center for Clinical Management Research
Current Funded Research Projects
In FY 2016 our core investigators served as PIs on 20 HSR&D IIR grants, 2 CREATEs, 1 CSR&D IIR, 1 QUERI SDP, 1 QUERI PEC project, 3 grants from VA partners, 1 VA Cooperative Studies Project, 9 NIH grants, 3 AHRQ grants, 1 CDC grant, and 1 DoD grant. We also completed the first year of our two new QUERI programs: PROVE (“PeRsonalizing Options for Veteran Engagement”), which builds directly off of our work in Focus Areas 1 and 3; and “Implementing Goals of Care Conversations with Veterans in Long-Term Care Settings” (Focus Area 1). In the paragraphs below we highlight the new HSR&D-funded projects that started in FY 2016.
Three new projects from Focus Area 1 were initiated this past year, all seeking to improve the delivery of high quality care through the development of improved systems for measuring both processes and outcomes of care. Dr. Pfeiffer is leading a team of CCMR investigators to incorporate treatment outcomes into quality measurement of depression care (IIR 14-345). Depression affects an estimated one million VA patients each year and is a leading cause of disability and suicide death. There are several effective treatments for depression, yet the degree to which these treatments improve depression symptoms depends on the quality of care provided. Current VHA quality measures for depression mostly emphasize care processes, such as the number of days of medication dispensed or the number of psychotherapy sessions attended. However, comprehensive quality measurement should include assessments of whether the ultimate goal of care--improved patient outcomes--is achieved. Incorporating patient-reported outcomes into quality improvement is a health system priority and has recently been recommended by the Institute of Medicine. However, systematically collecting patient-reported outcomes is challenging. This study will collect depression symptoms (measured by the Patient Health Questionnaire, PHQ-9) directly from patients using an automated, telephone-based interactive voice response (IVR) system. These data collected across clinics in VISN 10 will be used to develop and test clinic-level outcome quality measures (OQMs). OQMs, after case-mix adjustment, will allow determination of the structure and process measures (including a new measure of treatment intensification) associated with improved outcomes. Findings will enable leaders to identify under-performing clinics and the key aspects of care to address in order to achieve better depression outcomes for patients.
Dr. Kerr and her team will be devoting their efforts on opportunities for identifying and reducing over-use of inappropriate care—care that exposes patients to services that are not beneficial or may cause harm, and which may take scarce resources away from those who could benefit from them (IIR 15-131). They will focus on promoting de-intensification when care is too frequent or too intensive in cases where the marginal benefit is absent or there is potential for harm, and when both providers and patients have particular difficulty stopping testing and treatments once they have become part of a patient's routine care. Yet, most quality monitoring and improvement initiatives continue to provide incentives to escalate care intensity. Identifying, measuring, and facilitating appropriate de-intensification to complement the many measures promoting appropriate intensification is critical to restoring balance to our efforts to improve care quality. The specific aims of this study are: (1) to identify and validate clinical indications for de-intensification in primary care; (2) to assess prevalence and reliability of measures of de-intensification in VHA; and (3) to develop multi-component strategies to disseminate and implement de-intensification.
The third new study in Focus Area 1 is being led by Dr. Min, who is seeking to develop a novel measure of appropriate hypertension care for older Veterans, which is specific to age group, co-morbidity burden, and baseline risk for cardiovascular illness and falls (IIR 14-083). The motivation for this effort is the concern that our existing dichotomous blood pressure (BP) targets result in inadvertently low BPs, especially as aging Veterans develop geriatric conditions such as fall risk. We have previously found that nearly one-third of older Veterans with diabetes are potentially over-treated for hypertension. Therefore, Dr. Min and her team aim to define Aggressive Hypertension Care (AHC) in Veterans age 65 and older using national VHA databases. After validating a measure of AHC using medical record review, they will test whether AHC (in comparison to adequate care) is associated with falls injury, and whether the risks outweigh reduction in strokes and cardiac events. They will then measure inter-facility variation in AHC. VHA providers will be involved throughout the study, to review results, guide analytic decisions, and provide early identification of potential barriers to implementation.
Our newest project in Focus Area 2 is examining the effects of a VHA systems approach (dissemination of FDA warnings) on drug safety—specifically, the prescription of psychotropic medications (IIR 14-324). Drs. Sales and Zivin are leading this effort to examine VHA system and provider-level responses to external warnings regarding psychotropic medications, with the goal of developing and sharing best practices to inform future strategies for improving warning adoption, thereby improving patient care and population safety. They will use two examples of recent warnings designed to mitigate risks associated with psychotropic medications: (1) sudden cardiac events associated with high doses of citalopram (Celexa); and (2) impaired driving associated with zolpidem (Ambien). Their specific aims include: (1) to assess and describe PBM and VISN-level responsiveness to warnings; (2) to assess prescribing patterns before and after warnings; and (3) to understand specific strategies used by facilities and providers with high response to warnings and barriers encountered by facilities and providers with low response to warnings.
Our efforts to improve the effectiveness and efficiency of patient self-management and treatment engagement (Focus Area 3) include Dr. Heisler’s new project, which is evaluating the implementation of a peer-support program for enhancing diabetes shared medical appointments (IIR 15-321). This project will evaluate the implementation of diabetes shared medical appointments (SMAs) in five VA health systems, with some SMA cohorts being offered a novel program that was found in Dr. Heisler’s HSR&D-funded RCT to significantly improve VA patients' diabetes-specific social support, insulin starts, and glycemic control compared to usual nurse care management. The program uses periodic group sessions in conjunction with regular (weekly) calls between paired patients to promote more effective self-management through communication between patients who both have poor glycemic control and are working on similar care goals. "Peer buddies" are encouraged to provide mutual support and share their progress on meeting their self-management goals. The objective of this program is to enhance the effect of SMAs, including maintaining improvements in self-management and outcomes over time.