Abstract
BackgroundTransient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles.MethodsThis stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability.DiscussionPREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines.Trial registrationclinicaltrials.gov: NCT02769338 [May 11, 2016].
Highlights
Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%
Using a mixed-methods approach grounded in the Consolidated Framework for Implementation Research (CFIR), we examined and evaluated the degree to which the sites engaged in the three primary implementation strategies; the association between implementation strategies and implementation success; contextual factors associated with implementation success; the association between implementation strategies and the without-fail rate; and the association between implementation outcomes and the without-fail rate
Key strengths of the approach to developing this QI program involved grounding the program in data from multiple sources including interview data to understand the needs of front-line providers across a diverse set of facilities and across disciplines [15]; validation evidence identifying processes of care that could be obtained as electronic quality measures which facilitates ongoing performance measurement and scalability [14]; benchmarking data identifying the gaps in care that should serve as targets for quality improvement, especially processes with large opportunities for improvement for large numbers of potentially eligible patients [14]; and evidence from the existing literature about processes of care that are most robustly associated with improved patient outcomes [25,26,27,28]
Summary
Context Within the VA, quality measurement and systems redesign are integrated into the healthcare system within administration and clinical operations [19, 20]. Several secondary effectiveness analyses were prespecified, including [1]: an examination of how the without-fail rate changed in the PREVENT sites compared with VA facilities matched on the basis of TIA patient volume, facility complexity (i.e., teaching status, intensive care unit level),and baseline without-fail rate (with six controls for each intervention site); this analysis allowed for consideration of temporal changes in care [2]; an examination of individual processes of care across the six sites from the baseline period to active implementation period (e.g., how did receipt of high or moderate potency statins change from baseline to active implementation) [3]; an assessment of change in the consolidated measure of quality from baseline to active implementation; and [4] a comparison of the 90-day recurrent stroke rate and the 90-day all-cause mortality rate, before versus after active implementation. Structure: Facility team members engaged in quality improvement Process: Facilitation contents and dose
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