Clinical practice guideline implementation strategy patterns in Veterans Affairs primary care clinics

Health Services Research, Feb, 2007 by Sylvia J. Hysong, Richard G. Best, Jacqueline A. Pugh

Clinical practice guidelines (CPGs) have been used increasingly to standardize diagnosis and treatment procedures based on the latest clinical evidence, and thereby improve the quality of care. The Veterans Health Administration (VHA), the largest integrated health care system in the United States, mandated the implementation of CPGs throughout all its facilities starting in 1996; supportive resources were provided including Veterans Affairs (VA) developed or approved CPGs, external performance evaluation on guideline-specific measures, an electronic medical record with clinical reminder capabilities, and national training sessions on implementation principles (Kizer 1996). Since that time, VA has shown marked improvement in quality of care compared with previous performance levels (Jha et al. 2003). Further, recent research indicates the care currently provided at VA facilities is better than that provided by Medicare fee-for-service program participants as reflected in 11 of 13 preventive, outpatient, and inpatient quality of care indicators (Jha et al. 2003). Research comparing VA care to care provided by the private sector similarly found VA delivered higher quality of care overall, with particular advantages in chronic disease and preventive care (Asch et al. 2004), and comparable performance in chronic disease care to commercial managed care organizations (Singh and Kalavar 2004). Despite these improvements, significant performance variability still exists among individual facilities (Doebbeling et al. 2002; Krein et al. 2002; Fung et al. 9004). Given increasingly positive perceptions and evidence of the utility of CPGs in improving quality of care (VanOstenberg 1996; Smith and Hillner 2001; Bartell and Smith 2005; Pagaiya and Garner 2005), it is important to identify factors associated with CPG implementation success.

Previous research has identified several potential sources of variability including differences in mental models toward guidelines (Hysong et al. 2005), leadership style and commitment (Best et al. 2003), knowledge of the guidelines (Ward et al. 2002), organizational features, and patient population characteristics (Vaughn et al. 2002). Another source of variability in implementation success may lie in the strategy patterns used by individual facilities to implement CPGs. Strategies such as peer opinion leaders, academic detailing, and audit and feedback, have been associated with implementation success of specific guidelines (Jamtvedt et al. 2000; Thomson O'Brien et al. 2000; Markey and Schattner 2001). However, research identifying patterns of strategies associated with implementation success across multiple guidelines is more scarce.

CPG IMPLEMENTATION: EVIDENCE FROM TRIAL STUDIES

CPG implementation research has examined the effect of various strategies on implementation success; reviews by the Cochrane Effective Practice and Organization of Care Group (EPOC) have identified over 20 categories of implementation interventions (Grol, Wensing, and Eccles 2005). Trial studies of single strategies suggest that certain strategies, such as peer opinion leaders, academic detailing, and clinical reminders, are useful for implementation in specific situations. Trial studies evaluating multifaceted intervention strategies have yielded varying results in identifying an optimal combination of strategies for improving CPG adherence. Similar to the single intervention research, multifaceted interventions yield positive results for condition-specific outcomes (Frijling et al. 2003), but evidence on the effectiveness of multifaceted interventions on guideline implementation as a whole is less clear. A recent review of the area found (Grimshaw et al. 2004) "multifaceted interventions did not appear to be more effective than single interventions and the effects of multifaceted interventions did not appear to increase with the number of component interventions" (p. 61), in part due to considerable variation in the outcomes of the studies reported in the review.

Further complicating the translation of these findings to the real world of health care delivery, most health care facilities must address multiple CPGs simultaneously, not sequentially or individually as has been examined in the published trims. Research has suggested that when multiple CPGs are applied simultaneously to patients, significantly more time is required than is available in a typical patient visit, and in some cases could have adverse effects (Boyd et M. 2005; Ostbye et al. 2005); hence the need to study guideline adherence across multiple conditions. Published research has yet to address what patterns of strategies work best to implement multiple CPGs simultaneously. The present study addresses this gap by qualitatively comparing implementation strategies used by VA primary care clinics that have high and low levels of adherence for six different CPGs.

METHOD

Site Selection

The present data are part of a larger data collection effort at 15 VA facilities, which examined barriers and facilitators to CPG implementation. The original 15 facilities were selected using a stratified purposive sample from four geographically diverse regional networks based on their adherence to CPGs: facilities with a sustained record of high adherence to CPGs (high performing facilities, or HPF); a sustained record of low adherence to CPGs (low performing facilities, or LPF), and whose adherence record had significantly improved over a 2 year period (improvers). Group membership was determined via External Peer Review Program (EPRP) rankings, a random chart abstraction process conducted by an external contractor to audit performance at all VA facilities (see EPRP rankings section). Additionally, to be eligible, facilities had to be sufficiently large to accommodate at least two primary care teams, each containing at least three MD providers. To address the present paper's specific research question, only sites from the high (n = 3) and low (n = 3) performing categories were included in the sample. Despite its small size (which would be inadequate were we using it to conduct probability-based hypothesis tests), a purposive sample of this sort, if selected rigorously, i.e., "explicitly and thoughtfully picking cases that are congruent with the study purpose and that will yield data on major study questions" (Patton 1999), can yield important findings not often discoverable through more probabilistic methods (Devers 1999). As Daft and Lewin (1990, p. 6) pointed out regarding studies of organizations: "The average organization does not exist and by definition is never on the frontier of the phenomenon under study.... The use of outlier research--studying the best and worst cases--is helpful when making prescriptive recommendations for practice." The included sites ranged in size and type from small, rural, general medicine and surgery centers (approximately 20,000 patients) to large tertiary care facilities in major metropolitan areas (> 80,000 patients). This reflects the general distribution of Veterans Affairs Medical Centers across the country.