Session number: 1079
Abstract title: Economic Factors Influence the Intensity of Clinical Practice Guideline Implementation
Author(s):
S. Flach - University of Iowa College of Medicine and Public Policy Center
KD McCoy - Program in Health Services Research, Iowa City VAMC, and Department of Internal Medicine, The University of Iowa College of Medicine
BJ BootsMiller - Program in Health Services Research, Iowa City VAMC, and Department of Internal Medicine, The University of Iowa College of Medicine
RF Woolson - Department of Biostatistics, University of Iowa College of Public Health
BN Doebbeling - Program in Health Services Research, Iowa City VAMC, Department of Internal Medicine, University of Iowa College of Medicine
Objectives: The VA has promoted clinical practice guidelines (CPGs) to improve the quality of care by distributing them to VAMCs nationally and selecting performance measures to monitor. CPG implementation decisions are made by each facility. The factors determining the intensity of implementation efforts are important to understand, since more intensive implementation may increase adherence. We hypothesize that transaction costs, resource availability, and need to reduce hospitalizations would influence intensity of CPG implementation.
Methods: We used data from a 2001 national survey of key informants at 126 of 138 VAMCs (91 percent) to determine how intensively four CPGs (COPD, Depression, Diabetes, CHF) distributed by the VA were implemented. Facility-level implementation intensity scores (IIS, range 0-13) were calculated, defined as the sum of implementation approaches used (e.g. grand rounds, reminders, lectures). We identified explanatory variables reflecting transaction costs (ease of communication and coordination within the hospital), resource availability, and use of hospital resources from our study, the American Hospital Association Annual Survey, the Veteran’s Satisfaction Survey, and the Veteran’s Health Surveys. Factors influencing the CPG IIS for each of four CPGs were modeled at the hospital level using reverse stepwise OLS regressions.
Results: Intensity of CPG implementation was related to transaction costs, resource availability, and use of hospital resources. Factors from our VA survey reflecting reduced transaction costs were significantly related to a greater IIS in multiple models: teamwork (COPD, CHF, Depression), experience with CPGs (COPD, CHF, Diabetes), coordination between CPGs and other activities (Diabetes), and communication between physicians and nurses (Diabetes). Sufficient financial support was positively associated with the Depression CPG IIS. Two hospital utilization measures, occupancy rate and ratio of inpatient days to non-emergency outpatient visits, were positively related to the IIS for all models.
Conclusions: Reduced transaction costs, greater inpatient utilization, and greater resource availability are associated with a greater CPG implementation intensity. More intensive CPG implementation may be facilitated by the need to reduce resource use and the ability to coordinate complicated activities.
Impact statement: Even in an era of limited resources, improved communication and coordination within a VAMC may lead to more intensive CPG implementation. CPG participation can be improved with organizational interventions.