The purpose of this study is to design and evaluate targeted implementation strategies to fully integrate the VHA clinical practice guidelines for ischemic heart disease into VHA clinical practice. Effectively implementing the guideline will enhance the quality, appropriateness, timeliness, and cost effectiveness of care delivered to veterans with ischemic heart disease.
The long-term objective of this study is to identify the best strategies for implementing the IHD guidelines to improve guideline adherence and provider acceptance. The specific objectives of the study are to: 1) describe the temporal aspects of guideline acceptance and adherence over three periods of time: pre-implementation, post-implementation of general strategies, and post- implementation of targeted strategies; 2) assess the relative effectiveness of targeted intervention strategies on guideline adherence; 3) identify the relationships among provider beliefs, attitudes, and their intentions to use guidelines; 4) identify the costs associated with implementation of general and targeted implementation strategies; and 5) describe provider satisfaction with targeted implementation strategies.
Qualitative (focus groups, interviews with key informants) and quantitative methods (surveys, chart reviews) are used to address study objectives. A survey will be sent to providers to measure beliefs and attitudes that predict provider acceptance to clinical practice guidelines. Patient level data will be collected from reviews of charts from each facility. Based on provider focus groups we will design targeted strategies to overcome system barriers and address needs identified by providers to support clinical practice guideline implementation. A randomized trial will be conducted to assess the relative effectiveness of the targeted intervention strategies.
We have evaluated level of adherence to the VA Care Guide for Ischemic Heart Disease in the period before (10/1/96 -9/30/97)) and after dissemination (1/1/98 - 12/31/98). MI discharged before guideline dissemination demonstrated appropriate utilization of aspirin and beta-blockers at rates similar to those treated following dissemination (96% vs. 94%; p = 0.65, and 92% vs. 90%; p = 0.41, respectively; n = 491). Similarly, patients with congestive heart failure had appropriate utilization an ACEI or ARB at similar rates before and after guideline dissemination (90% vs. 89%, p = 0.86, n = 508) as did patients with hyperlipidemia regarding cholesterol-lowering therapy (88% vs. 93%, p = 0.10, n = 398). There was a modest trend in favor of increased utilization of cholesterol lowering medications in Phase II vs. Phase I. In addition, focus groups were conducted at three of the study’s intervention sites in VISN 8. We found that in general, providers support the use of guidelines. They believed that using the guidelines would result in an improved quality of care for their patients, and would eventually save lives. They appreciated the guidelines as a quick and ready reference but felt the guidelines were too long and disorganized. They recognized the administrative use of guidelines to stimulate quality improvement initiatives, to shorten the time to incorporate research into practice, to provide standards of care that could be used as legal protection, and to achieve cost effective care. The results of the focus groups were used to develop a written questionnaire that was returned by 174 providers in VISN 8. The results of the survey support the findings of the focus group.
This study represents one of the first VISN-wide efforts to evaluate the impact of clinical practice guidelines in the VHA. The study will result in the development of tools and strategies for the efficient integration of these clinical practice guidelines that can be used in other clinical settings in the VHA.
External Links for this Project
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