2041. VA Diabetes Hypertension Guideline Implementation Strategies
CP Kowalski, Ann Arbor VA HSR&D, JC Lowery, Ann Arbor VA HSR&D, L Wyszewianski, University of Michigan, LA Green, University of Michigan

Objectives: Although educational and simple dissemination strategies are the approach most often favored for implementing practice guidelines, these approaches seldom result in lasting practice changes. Previous research has shown that multi-faceted approaches tend to have more positive effects. What kinds of approaches are used in VA medical centers? The objective of this VA HSR&D-funded study was to determine what strategies have been implemented in VA medical centers for meeting diabetes hypertension guidelines, as the first phase in a larger study to determine which strategies are most effective.

Methods: Eighty-six semi-structured telephone interviews with an average length of 38 minutes were conducted with two of the following individuals at each of 43 participating VAMCs:  Chief of Staff, Chief of Medicine, Associate Chief of Staff for Ambulatory Care, Quality Manager, Director of Primary Care, and attending physicians.  The purpose of these interviews was to determine what strategies were implemented for meeting diabetes hypertension guidelines from 1999 through 2001.

Results: All of the sites chose to implement some type of educational intervention, whether written (41 sites) or a presentation or conference (37 sites). Thirty-four sites (79%) implemented some type of reminder system for hypertension. Forty sites (93%) provided group feedback and 39 sites (91%) provided individual physician feedback on hypertension. Seven facilities (16%) initiated monetary incentives in the form of cash awards ranging from $200 to $3,000 for outstanding performance on the guidelines and VA performance measures. Twelve sites (28%) identified local barriers (e.g., limited time, staffing, and computers) to implementing hypertension guidelines and worked to remove those. Five sites (12%) instituted penalties for non-compliance with VA goals and guidelines.

Conclusions: Unfortunately, the most common strategies used by VA medical centers—traditional continuing education and simple dissemination—have been shown in previous research to be ineffective in guideline implementation.  Instead, organizational, motivational, and multi-faceted interventions tend to be more effective at changing behaviors.  More medical centers could benefit from implementing innovative ideas from other sites, such as monetary incentives, penalties, and barrier removal.

Impact: The interview results provide specific examples of multi-faceted approaches for translating research into practice.