Using QUERI & Implementation Science Theories and Frameworks to Improve Access and Equity

S. Randal Henry, DPH, MPH

QUERI HIV/Hepatitis C

Preface

Overview 

Does implementation of disparities reduction programs differ from general quality improvement interventions?

How can implementation science contribute to disparities reduction research?

How can collaboration and partnership-building contribute to the reduction of health disparities?

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: An Ideal Environment for Disparities Research
        - 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

VA HSR&D and Disparities Research
        - 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

Poll Question
        - Does the implementation of access and equity improvement interventions differ from general quality improvement (QI) interventions?
        - Yes
        - No

Cyber Seminar Goals

CyberSeminar 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  

The key goals of this Cyber Seminar are to:

(a) introduce the VA implementation research community to equity issues, and encourage them to address these issues in their research, and 

(b) encourage the equity community to learn about (and use) implementation research frameworks. 

promote use of implementation science frameworks, theories and methods in the disparities field -- to guide efforts to develop, evaluate and refine programs and strategies to reduce disparities.  

Introduction:

The VA is committed to delivering high quality

healthcare care in an equitable manner.

The VA is a Safety Net Provider 

Many of the veterans served are psychologically or economically disadvantaged and there is a high disease burden

What are Health Disparities?

Health disparities are 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)

Quality Chasmgaps in the quality, safety, equity, efficiency, timeliness and patient-centeredness of health care delivery 

(due to insufficient use of evidence-based practices)

Patient-level Characteristics

Socioeconomic status

Health/MH status

Medical knowledge and information sources

Stigma

Racial/cultural milieu

Organizational Characteristics

Healthcare Systems

Information Technology

Facility characteristics

Provider-level variables 

Clinician judgment

Communication Skills---Care Processes

Care coordination

Racial/cultural milieu---CLAS (Culturally, Linguistically Appropriate Services) 

Differences... 

in the quantity and quality of healthcare provision 

Ex: Non-whites undergo fewer cardiac procedures than whites  

Ex: The quality of care- as measured by process measures (appropriate test ordering) and outcome measures (control of bp, glucose, lipids)-appears to be worse for non-white veterans compared to whites. 

in the prevalence, mortality, and burden of disease and other adverse health conditions (CHERP)

Ex: Ex: Shorter life expectancy in A.A. males [In 1996 African American men had a life expectancy of 66 yrs vs white males 74yrs]

not due to access related factors, clinical need, preferences, or appropriateness of the intervention (IOM)

ADD EXAMPLE: May be caused by bias, stereotyping, prejudice, and clinical uncertainty on the part of providers. 

Many sources- including health system factors, healthcare providers, patients, and the economic environment - may contribute to racial and ethnic disparities in healthcare.

Poll Question

In the course of your research or clinical practice, have you identified a health disparity?

Yes?

No?

Evidence 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. 

          - Non-white veterans generally fare worse than whites
          - Disparities have been demonstrated in the VA----where financial barriers are minimized. (Saha et al)
          - Within the VA, everyone has essentially the same access to care because financial barriers are minimized

Inequities 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

More consistently observed for processes that:

-entail more risk 

-require more intensive decision making & communication 

EXAMPLE Less engagement by the physician may partially explain why blacks are less likely to undergo surgical cancer interventions, despite that they’re equally as likely to undergo non-surgical interventions 

-require more effort on the part of patients and/or providers 

EXAMPLE Racial differences in joint replacement surgery and analgesic medication use indicated less aggressive management of osteoarthritis in blacks compared to whites. 

-surgery/invasive procedures

-medication adherence 

EXAMPLE African Americans more were less adherent (intentionally and unintentionally) to cardiac medication regimens 

--In studies examining quality indicators that represent intermediate health outcomes, non-white veterans generally fared worse than whites

Vulnerable Patient Groups
        - Racial/ethnic minorities
        - Women
        - Homeless
        - Elderly
        - Low socioeconomic status
        - Stigmatizing medical or psychiatric illness
        - Diminished autonomy

Disparities by QUERI 

Disparities By Clinical Content 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 |

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)

Disparities By Utilization/Outcome Measure
| 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                      |
| *E.g.: lab tests, outpatient visits                      |
|----------------------------------------------------------|
| **E.g.: control of blood pressure, blood glucose, lipids |

Polling Questions #2
        - What is the key barrier to improving access and equity for veterans?

Individual/patient-level factors 

Organizational/institutional factors

Which VA Programs Address Access and Equity?

        - 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

The VA may be able to address individual and institutional barriers to care EXAMPLE housing, geographic location, etc 

Center for Health Equity Research and Promotion (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

, a recent VA HSR&D report. 

VA Center for Minority Veterans
        - 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 

Part of the Office of the Secretary

Office of Quality and 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)

Operational focus on disparities:

Race/ethnicity

Technical process and intermediate outcome measures of quality

Patient Satisfaction

Gender

Technical Quality

Patient Satisfaction

OQP custodian of rich source of data for health disparities research 

Chronic pain (race)

Alcohol Counseling (race)

Immunization (gender)

Quality of Care (mental health, MS, SCI, Chronic illness, rural/urban)

Poll  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?

Implementation Science (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

the scientific study of methods to promote the systematic uptake of research findings (and other evidence-based practices) into routine practice, and, hence, to improve the quality and effectiveness of health services and care.

This relatively new field includes the study of influences on healthcare professional and organizational behavior.

implementation projects are hybrid research/practice initiatives involving complex social/behavioral phenomena

implementation projects require a unique set of design features, methods, skills and competencies

IS research requires considerable foundational research :

Clinical, health behavior and health services research to develop evidence-based practices and care models  

Systematic reviews to develop guidelines   Epidemiological research to identify target conditions Variations studies (observational quality measurement) to document processes and identify and diagnose quality gaps 

and observational studies of natural change Survey studies of delivery system structure  

Methods and measure development work (develop and validate measures of structure, process and outcome

Implementation Science 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

Implementation science can help improve access and equity for vulnerable patient groups by designing, delivering, evaluating, refining and facilitating national roll-out or spread of effective disparity reduction strategies and programs.

Four Implementation Science Frameworks that can be used to Assess Access and Equity

Framework/theory/model 

Conceptual framework

Identifies a set of variables and relationships that should be examined in order to explain the phenomena [Kitson et al., 2008, per Ostrom]

Theoretical framework 

More specific and concrete than theory, and can usually be shown in a diagram or picture [e.g., PARIHS; RE-AIM] [Sales et al, 2006]

CHERP Conceptual Model for Health Disparities Research

First 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

Behavioral Model of Vulnerability

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)

PARIHS Framework

Successful

Implementation   	  = 

	f (E, C, F)
        - Evidence

=  Research; Clinical experience;  Patient experience; & Local knowledge
        - Context

= Receptive context; Culture; Leadership; & Evaluation
        - Facilitation

= Purpose; Role; Skill & Attributes

Promoting Action on Research Implementation in Health Services (PARIHS) 

Posits that successful research implementation is a function of 

Evidence assessment (research, clinical experience, patient experience and routine information)

Content assessment (organizational features, culture, innovation environment)

The way the process is facilitated (human support, guidance, learning, “readiness”) 

PRECEDE PROCEED Framework

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 Promotion 

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 

Health

Quality of Life

PRECEDE

PROCEED

PRECEDE-PROCEED [Discuss how the PRECEDE-PROCEED can specifically be used to target inequality ]

The PRECEDE-PROCEED model provides a comprehensive structure for assessing health and quality-of-life needs and for designing, implementing, and evaluating health promotion and other public health programs to meet those needs. 

PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) outlines a diagnostic planning process to assist in the development of targeted and focused public health programs. 

PROCEED (Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) guides the implementation and evaluation of the programs designed using PRECEDE. (encyclopedia of public health)

Polling Questions # 3
        - What is the key barrier to Quality Improvement (QI) in medical care delivery?

Individual factors 

Societal Factors

VA related organizational/institutional factors

IV.  Utilizing the QUERI Model to Improve Access and Equity

This framework is consistent with other models that look at detecting, understanding , and reducing disparities, like the Kilbourne framework, or the Andersen-Gelberg Behavioral Model for vulnerable populations, etc.

QUERI 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.

David Atkins, QUERI Director :

QUERI work (along with HSRD) has (and should continue to) identified those areas where disparities exist and what the most important contributors are (i.e. race, gender, geography, age).  

QUERI also explicitly examines barriers to delivery or receipt of needed services, which can then help in the design of interventions aimed at overcoming the source of the disparities. 

For example, if a source of disparities is difficulty with transportation and frequent missed appointments for patients with multiple co-morbidity, then designing a care process where patients can address multiple needs on one day or in one visit will be necessary.  

	QUERI projects have examined the role of collaborative care in specific conditions (i.e. mental health) and in combination of disorders (e.g. depression and substance abuse).  These lessons can be applied to a more diverse set of patients.  

	QUERI may need to be creative to tackle these issues of multiple comorbidity that do not fall neatly in one center.  We will need to support collaborative projects across centers and think about how systems redesign may offer some solutions to challenges of integrated care. 

QUERI’s ROLE AND FUNCTION:

Improve health care practices and outcomes through scientifically-based implementation. Create successful and sustainable implementation practices. Create replicable approaches for generic situations.

QUERI Four-Phase Implementation Research Framework

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 ongoing

		intervention support; emphasis on internal validity

Phase 3	Effectiveness	Large-scale rigorous trial under routine conditions in varied

		settings; emphasis on external validity

Phase 4	Monitoring  	Ongoing monitoring and feedback 

The Classic Six-Step  QUERI Process

Identify high risk/high burden conditions

Identify best practices

Define existing practice patterns in VA and variations from best practices

Identify (or develop) and implement programs to promote best practices

Document outcome and system improvements

Document improvements in health-related quality of life 

Measure existing practice patterns and outcomes and identify variations from evidence-based practices

Baseline measurement of HIV screening prevalence 

Determine current practices + barriers and facilitators

Measurement of delays in laser therapy for diabetic retinopathy and reasons for delays 

Diagnose quality gaps and identify barriers and facilitators to improvement

Survey of variations in HIV provider attitudes and facility policies for HIV care 

Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Identify quality improvement strategies, programs, program components, or tools 

Literature reviews

Develop or adapt quality improvement strategies, programs, program components, or tools 

Integrate CLAS/cross-cultural education into training of all health professionals 

Implement quality improvement strategies, programs, program components, or tools 

Implement multidisciplinary treatment programs 

Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

Assess feasibility, implementation, and impacts on patient, family, and system outcomes

 Evaluation of a foot care intervention for diabetic patients

Assess impacts on health-related quality of life (HRQOL)

 Evaluation of eye and foot care interventions for reducing blindness, amputation, and improvements in HRQOL 

V.  Next Steps

Using Implementation Science to Study and Promote Equity 

V.  Next steps:  using implementation  science to study and promote equity

Slides that propose specific activities and actions by equity researchers and implementation researchers to move forward in this initiative

Future Directions for VA Disparities 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 

Opportunities exist for fostering collaborations to improve equity – but they may need to incorporate quality into the equation.
          - Currently, VA is conducting research to drill down on a recently released quality report card that showed minority veterans to be less satisfied with their care than on-minority veterans.
          - RWJ initiative might offer some synergies and ideas, “Known as Aligning Forces for Quality, the program aims to lift the overall quality of health care, reduce racial and ethnic disparities and provide models for national reform.”  

Poll
        - 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)

Summary
        - 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

          - Another opportunity may lie in broadening the scope of cooperation between DOD and VA to include examinations relating to SES/race and the current veteran cohort.  While TBI and PTSD are important health issues, the integration of all of the OIF/OEF veterans into the VHA will present challenges and at the same time research opportunities.
          - In closing, I would like to say that health inequities among veteran populations reflect inequities in the larger US populations.  And for that reason, I think that there are many many opportunities for VA and other federal agencies to collaborate to improve health equity.  These may include
          - Better facilitation of cross-agency data use.
          - Collaborations that meet the needs of vulnerable veteran populations – for example. VA and HUD may be able to address issues of homeless veterans better together.  The US Department of Education might also offer some valuable information to improving the SES of returning veterans and others.

*

VA HSR&D

CHERP

VA CIPRS

VA QUERI (esp. HIV/Hepatitis C)

OQP

Acknowledgements 

Laurel N.veVA HSR&D 

Steven M. Wright, PhD – Office of Quality and Performance

David Atkins, MD, MPH - QUERI