Health System Quality Improvement Research Articles

Sexually Transmitted Infection Prevention Services for Women Experiencing Homelessness: A Safety-Net Health System Quality Improvement Initiative.

Consistent use of sexually transmitted infection (STI) prevention methods is proven to decrease transmission of STIs. Yet, rates continue to rise within the US, particularly among high-risk populations. Women experiencing homelessness may face barriers to access reproductive healthcare. This quality improvement (QI) initiative sought to examine perceived barriers to STI prevention and opportunities for expanding STI prevention services and education for women experiencing homelessness. Surveys were administered during a one-day health event in August 2023 at a clinic that predominately serves persons experiencing homelessness in North Texas. Respondents included adult, non-pregnant, English-speaking, individuals assigned female at birth with a history of homelessness. Demographic characteristics, sexual history, participants' knowledge of STIs, and perceived barriers to obtaining sexual health care were gathered. Participants had the opportunity to suggest methods for improving access to STI care. Among participants (n = 36), over half (59%) were tested for STIs within the past year. Most preferred condoms for STI prevention. The average knowledge score among questions about STI transmission and methods of prevention was 65%, with the lowest scores observed among trichomoniasis (39% correct), pre-exposure prophylaxis (PrEP; 31%), and dental dams (25%). Common barriers included cost (33%) and side effects (33%). One-third (36%) of participants reported no barriers to the use of prevention products. Findings highlight the need for educational opportunities among this population to increase knowledge of STI transmission and prevention. Patients may benefit from clinicians emphasizing education and increasing the visibility of services.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa.

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Abstract 15849: Studying the Effects of Race, Community Health, and Vascular Inequities on Outcomes for Peripheral Artery Disease: Principal Components Analysis of Community Health Metrics Using the Agency for Healthcare Research and Quality Social Determinants of Health Database

Introduction: Healthcare disparities associated with peripheral artery disease (PAD) are influenced by differences in healthcare quality and social determinants of health (SDOH). Hypothesis: We used principal components analysis (PCA) to summarize key themes of community-level SDOH variables. Methods: This retrospective analysis used data from a single health system quality improvement database of patients diagnosed with PAD between 2016-2019. Subjects were geocoded to census tracts and variables from the Agency for Healthcare Quality and Research SDOH database were obtained to examine small-area variability in social, economic, educational, physical infrastructure, and healthcare contexts. PCA was used to identify major themes in SDOH heterogeneity across communities. Relevant SDOH variables were normalized within a data matrix and those with a loading value >0.2 were retained in a principal component (PC). PCs with an eigenvalue > 1.0 were identified to parsimoniously exemplify key themes. Results: Among 7,187 subjects with PAD, the mean age was 72.2 11.1 years, 45.9% were female, 9.4% self-reported as non-Hispanic Black, and 86.6% as non-Hispanic White. PCA was applied to 29 SDOH variables relevant to vascular health. PCA retained 6 PCs to an SDOH matrix describing 73.8% of variance in census tract level data. The greatest variance in data was attributed to socioeconomic advantage (PC1) and urbanicity/migration context (PC2) with some overlap in Black neighborhood context (PC3), income inequality (PC4), multi-race cohesion (PC5), and underrepresented minority context (PC6). Conclusions: PCA transforms high-dimensional SDOH data into distinct typologies of community health while retaining complex features of the data. Future analysis will weight these results within a hierarchical model that accounts for patient-level characteristics and quality of care to inform a more complete social-ecological model of whole-person vascular care.

Zero Suicide Quality Improvement: Developmental and Pandemic-Related Patterns in Youth at Risk for Suicide Attempts

ABSTRACT The Zero Suicide (ZS) approach to health system quality improvement (QI) aspires to reduce/eliminate suicides through enhancing risk detection and suicide prevention services. This first report from our randomized trial evaluating a stepped care for suicide prevention intervention within a health system conducting ZS-QI describes (1) our screening and case identification process, (2) variation among adolescents versus young adults, and (3) pandemic-related patterns during the first COVID-19 pandemic year. Between April 2017 and January 2021, youths aged 12–24 years with elevated suicide risk were identified through an electronic health record (EHR) case-finding algorithm followed by direct assessment screening to confirm risk. Eligible/enrolled youth were evaluated for suicidality, self-harm, and risk/protective factors. Case finding, screening, and enrollment yielded 301 participants showing suicide risk indicators: 97% past-year suicidal ideation, 83% past suicidal behavior; and 90% past non-suicidal self-injury (NSSI). Compared to young adults, adolescents reported more past-year suicide attempts (47% vs. 21%, p < .001) and NSSI (past 6 months, 64% vs. 39%, p < .001); less depression, anxiety, posttraumatic stress, and substance use; and greater social connectedness. Pandemic onset was associated with lower participation of racial-ethnic minority youths (18% vs. 33%, p < .015) and lower past-month suicidal ideation and behavior. Results support the value of EHR case-finding algorithms for identifying youths with potentially elevated risk who could benefit from suicide prevention services, which merit adaptation for adolescents versus young adults. Lower racial-ethnic minority participation after the COVID-19 pandemic onset underscores challenges for services to enhance health equity during a period with restricted in-person health care, social distancing, school closures, and diverse stresses.

Improving Care by Decreasing Wait Times: A Military Health System Quality Improvement Project.

Maximizing patient satisfaction is now a significant focus in many outpatient orthopedic clinics as it has been shown to affect many facets of healthcare. With this quality improvement study, we sought to determine the areas of the longest patient wait time during their clinical encounter and evaluate the effect of an identification card system on those times. We hypothesized that utilizing an identification card system would expedite the time patients spend in the clinic and decrease wait times. This quality improvement study was conducted in an orthopedic hand surgery clinic within a military treatment facility. Pre-intervention and intervention data collection consisted of a time sheet that was filled out by surgeons and clinic staff as the patient progressed through their appointment. The intervention consisted of a card system to track the patient throughout their encounter and mark their order in the queue. There were a total of 130 patients in the pre-intervention group and 113 in the intervention group. Compared with the pre-intervention group, the intervention group patients had significantly less time from check-in to being roomed by the clinic staff with a mean of 13 ± 13 vs. 21 ± 19 minutes in the pre-intervention group (P < .001). In the pre-intervention cohort, the average clinic encounter was 66 ± 38 minutes compared to 57 ± 35 minutes in the intervention cohort, which was not statistically significant (P = .112). The time spent with the orthopedic surgeon and occupational therapists increased in the intervention group. We provided a simple way to decrease patient wait times and increase time with the healthcare team, utilizing our existing clinic space. Time with the orthopedic surgeon significantly increased because of our intervention, while the overall clinic time trended down.

Healthcare personnel early return-to-work program after higher-risk SARS-CoV-2 exposure: A learning health system quality improvement project

BackgroundIncidence of health care personnel (HCP) with a higher-risk SARS-CoV-2 exposure and subsequent 14-day quarantine period adds substantial burden on the workforce. Implementation of an early return-to-work (RTW) program may reduce quarantine periods for asymptomatic HCP and reduce workforce shortages during the COVID-19 pandemic.MethodsThis observational quality improvement study included asymptomatic HCP of a multi-facility health care system with higher-risk workplace or non-household community SARS-CoV-2 exposure ≤4 days. The program allowed HCP to return to work 8 days after exposure if they remained asymptomatic through day 7 with day 5-7 SARS-CoV-2 nucleic acid amplification test result negative.ResultsBetween January 4 and June 25, 2021, 384 HCP were enrolled, 333 (86.7%) remained asymptomatic and of these, 323 (97%) tested negative and were early RTW eligible. Mean days in quarantine was 8.16 (SD 2.40). Median day of early RTW was 8 (range 6-9, IQR 8-8). Mean days saved from missed work was 1.84 (SD 0.52). A total of 297 (92%) HCP did RTW ≤10 days from exposure and days saved from missed work was 546.48.ConclusionsImplementing an HCP early RTW program is a clinical approach for COVID-19 workplace safety that can increase staffing availability, while maintaining a low risk of SARS-CoV-2 transmission.

Towards the development of a system-wide quality improvement maturity model: a synthesis using systematic review and expert opinion

PurposeThe various quality improvement (QI) frameworks and maturity models described in the health services literature consider some aspects of QI while excluding others. This paper aims to present a concerted attempt to create a quality improvement maturity model (QIMM) derived from holistic principles underlying the successful implementation of system-wide QI programmes.Design/methodology/approachA hybrid methodology involving a systematic review (Phase 1) of over 270 empirical research articles and books developed the basis for the proposed QIMM. It was followed by expert interviews to refine the core constructs and ground the proposed QIMM in contemporary QI practice (Phase 2). The experts included academics in two academic conferences and 59 QI managers from the New Zealand health-care system. In-depth interviews were conducted with QI managers to ascertain their views on the QIMM and its applicability in their respective health organisations (HOs).FindingsThe QIMM consists of four dimensions of organisational maturity, namely, strategic, process, supply chain and philosophical maturity. These dimensions progress through six stages, namely, identification, ad-hoc, formal, process-driven, optimised enterprise and finally a way of life. The application of the QIMM by the QI managers revealed that the scope of QI and the breadth of the principles adopted by the QI managers and their HOs in New Zealand is limited.Practical implicationsThe importance of QI in health systems cannot be overstated. The proposed QIMM can help HOs diagnose their current state and provide a guide to action achieving a desirable state of quality improvement maturity. This QIMM avoids reliance on any single QI methodology. HOs – using the QIMM – should retain full control over the process of selecting any QI methodology or may even cherry-pick principles to suit their needs as long as they understand and appreciate the true nature and scope of quality overstated. The proposed QIMM can help HOs diagnose their current state and provide a guide to action achieving a desirable state of quality improvement maturity. This QIMM avoids reliance on any single QI methodology. HOs – using the QIMM – should retain full control over the process of selecting any QI methodology or may even cherry-pick principles to suit their needs as long as they understand and appreciate the true nature and scope of quality.Originality/valueThis paper contributes new knowledge by presenting a maturity model with an integrated set of quality principles for HOs and their extended supply networks.

Organizational Costs and Benefits of a Health System Quality Improvement Intervention to Increase Aspirin Use for Primary Prevention of Heart Attack and Stroke.

Performance improvement on clinical quality outcomes typically requires significant effort by personnel in health care organizations. Understanding the cost of quality improvement is important given diffusion of value-based contracting. This study investigates the organizational costs and benefits associated with planning and implementing the Ask about Aspirin intervention to increase use of low-dose aspirin in clinically recommended patient populations. Data from 4 health systems in Minnesota were used to estimate personnel effort and labor resource costs as well as corresponding benefits, measured as the change in aspirin use among eligible candidates during the study period. Overall personnel effort across the 4 systems was approximately 3900 hours with corresponding resource costs estimated to be $214,385. Aspirin use increased 4.7% overall, corresponding to roughly 1530 new users in the aspirin candidate population. Significant variation was observed by system in total hours reported, distribution of effort by activity type, and in benefits realized from the intervention.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BackgroundWhen randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability...

Quality improvement of health systems in an epidemic context: A framework based on lessons from the Ebola virus disease outbreak in West Africa.

Quality improvement (QI) in health generally focuses on the provision of health services with the aim of improving service delivery. Yet QI can be applied not only to health services but also to health systems overall. This is of growing relevance considering that due to deficiencies in health systems, the main countries affected by Ebola virus disease (EVD) outbreak in West Africa (2014-2016) were insufficiently prepared for the epidemic, and according to the WHO, epidemics are increasingly becoming a threat to global health. Our objective is to analyze QI constraints in health systems during that EVD epidemic and to propose a practical framework for QI in health systems for epidemics in developing countries. We applied a framework analysis using experiences shared at the "Second International Quality Forum" organized by the University of Heidelberg and partners in July 2015 and information gathered from a systematic literature review. Empirical results revealed multiple deficiencies in the health systems. We systemized these shortfalls as well as the QI measures taken as a response during the epidemic. On the basis of these findings, we identified six specific "priority intervention areas," which ultimately resulted in the synthesis of a practical QI framework. We deem that this framework that integrates the priority intervention areas with the WHO building blocks is suitable to improve, monitor, and evaluate health system performance in epidemic contexts in developing countries.

Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania.

ObjectivesReduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub‐optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth.MethodsIn this cluster‐randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in‐service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference‐in‐differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation.ResultsThe intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup.ConclusionsWe attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality.

Establishing the Foundation to Support Health System Quality Improvement: Using a Hand Hygiene Initiative to Define the Process.

ObjectivesAs hospitals are increasingly consolidating into larger health systems, they are becoming better positioned to have far reaching and material impacts on safety and quality of care. When the Mount Sinai Health System (MSHS) was formed in 2013, it sought to ensure the delivery of safe, high-quality care to every patient. In 2014, the MSHS addressed hand hygiene as the first major system-wide process improvement project focused on quality and safety. The goals of this study were to evaluate a system-wide hand hygiene program and to create a foundation for future process improvement projects.MethodsThe MSHS implemented the Joint Commission’s Targeted Solutions Tool as a way to improve hand hygiene compliance and reduce harm from hospital-acquired infections, specifically Clostridium difficile infections. A multifaceted approach was used to improve hand hygiene and promote a culture of patient safety.ResultsThe MSHS improved hand hygiene compliance by approximately 20% from a baseline compliance of 63.3% to an intervention compliance of 82.8% (P < 0.001). Additional correlation analysis revealed a significant correlation between increasing hand hygiene compliance and reduction in C. difficile infections.ConclusionsThrough a focus on leadership engagement, data transparency, data and observer management, and system-wide communication of best practices, the MSHS was able to improve hand hygiene compliance, reduce infection rates, and build an effective foundation for future process improvement programs.

Hospitalist Value in an ACO World.

The accountable care organization (ACO) concept is advocated as a promising value-based payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency. Focusing on the care of hospitalized patients and controlling a substantive portion of variable hospital expenses, hospitalists are poised to play an essential role in system-level transformational change to achieve clinical integration. Especially through hospital and health system quality improvement (QI) initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care and the patient and family caregiver experience. Regardless of political terrain, financial constraints in healthcare will foster continued efforts to promote formation of ACOs that aim to deliver coordinated, evidence-based, and patient-centered care. Hospitalists possess the clinical experience of caring for complex patients with multiple comorbidities and the QI skills needed to lead efforts in this new ACO era.

Defining quality in contraceptive counseling to improve measurement of individuals' experiences and enable service delivery improvement

The field of family planning has been at the forefront of the movement to begin prioritizing quality of health care services as opposed to focusing more narrowly on coverage and utilization. A focus on quality in family planning began most notably with Judith Bruce's 1990 publication of a framework to assess quality from the client's perspective, informed by Avedis Donabedian's foundational definition of health care quality in terms of structure, process and outcome elements [ 1 Bruce J. Fundamental elements of the quality of care: a simple framework. Stud Fam Plann. 1990; 21: 61-91 Crossref PubMed Scopus (497) Google Scholar , 2 Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966; 44: 166-206 Crossref PubMed Scopus (3230) Google Scholar , 3 Donabedian A. The quality of care: how can it be assessed?. JAMA. 1988; 260: 1743-1748 Crossref PubMed Scopus (4511) Google Scholar ]. Bruce's publication came more than a decade before the United States (US) Institute of Medicine's groundbreaking report Crossing the Quality Chasm [ [4] Institute of Medicine Crossing the quality chasm: a new health system for the 21st century. National Academies Press, 2001 Google Scholar ] and the World Health Organization's publication of guidance for quality improvement in health systems [ [5] World Health Organization Quality of care: a process for making strategic choices in health systems. 2006 Google Scholar ], and has informed countless efforts to monitor and improve family planning programs. Its focus on quality from the client's perspective is in line with the now prominent “Triple Aim” framework which includes patient experience as one of three organizing principles of optimal health systems, in addition to cost and population health [ [6] Berwick D.M. Nolan T.W. Whittington J. The triple aim: care, health, and cost. Health Aff. 2008; 27: 759-769 Crossref PubMed Scopus (3392) Google Scholar ].

Engaging Learners in Health System Quality Improvement Efforts.

In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education.The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.

Improving opioid safety practices in primary care: protocol for the development and evaluation of a multifaceted, theory-informed pilot intervention for healthcare providers

IntroductionIn North America, drug overdose deaths are reaching unprecedented levels, largely driven by increasing prescription opioid-related deaths. Despite the development of several opioid guidelines, prescribing behaviours still contribute to poor...

Unintended Consequences of Adjusting Citalopram Prescriptions Following the 2011 FDA Warning

In 2011, the U.S. Food and Drug Administration (FDA) issued a safety announcement cautioning providers against prescribing citalopram above 40 mg per day given concerns for QT prolongation. We assessed the impact of a health system quality improvement initiative to identify patients taking higher than the recommended dose of citalopram. Retrospective cohort study. Nine primary care clinics within the University of Michigan from March 2012 to February 2013. Adult patients taking a higher-than-recommended dose of citalopram following the FDA warning in 2011 (N = 199). Frequency of EKG monitoring, clinical factors associated with patients whose citalopram dose or use was adjusted, and potential impact of these changes on overall health care utilization was assessed. In patients prescribed higher-than-recommended doses of citalopram and who received a note from a pharmacist regarding the FDA warnings, only 8.5% received electrocardiogram (EKG) monitoring. Patients who were converted to an alternative antidepressant from citalopram were more likely to receive subsequent new prescriptions for benzodiazepines and sedative hypnotics (χ2 = 7.9, p = 0.048). Patients who had any adjustments to their antidepressant medication had greater overall health care utilization (OR: 25.0; 95% CI: 5.7-109.6; p < 0.001) than patients remaining on the same dose of citalopram. Despite a targeted quality intervention to address the FDA warning regarding citalopram, the warning was associated with low levels of EKG monitoring, increased anxiolytic and sedative medication use, and higher healthcare utilization. This finding may represent destabilization of patients on previously therapeutic doses of their antidepressant and an unintended consequence of the FDA warning.

Health System Quality Improvement: Impact of Prompt Nutrition Care on Patient Outcomes and Health Care Costs.

Among hospitalized patients, malnutrition is prevalent yet often overlooked and undertreated. We implemented a quality improvement program that positioned early nutritional care into the nursing workflow. Nurses screened for malnutrition risk at patient admission and then immediately ordered oral nutritional supplements for those at risk. Supplements were given as regular medications, guided and monitored by medication administration records. Post-quality improvement program, pressure ulcer incidence, length of stay, 30-day readmissions, and costs of care were reduced.

PUBLIC AND PATIENT INVOLVEMENT IN HEALTH TECHNOLOGY ASSESSMENT: A FRAMEWORK FOR ACTION.

As health technology assessment (HTA) organizations in Canada and around the world seek to involve the public and patients in their activities, frameworks to guide decisions about whom to involve, through which mechanisms, and at what stages of the HTA process have been lacking. The aim of this study was to describe the development and outputs of a comprehensive framework for involving the public and patients in a government agency's HTA process. The framework was informed by a synthesis of international practice and published literature, a dialogue with local, national and international stakeholders, and the deliberations of a government agency's public engagement subcommittee in Ontario, Canada. The practice and literature synthesis failed to identify a single, optimal approach to involving the public and patients in HTA. Choice of methods should be considered in the context of each HTA stage, goals for incorporating societal and/or patient perspectives into the process, and relevant societal and/or patient values at stake. The resulting framework is structured around four actionable elements: (i) guiding principles and goals for public and patient involvement (PPI) in HTA, (ii) the establishment of a common language to support PPI efforts, (iii) a flexible array of PPI approaches, and (iv) on-going evaluation of PPI to inform adjustments over time. A public and patient involvement framework has been developed for implementation in a government agency's HTA process. Core elements of this framework may apply to other organizations responsible for HTA and health system quality improvement.

Opioid Dose Reduction in a VA Health Care System--Implementation of a Primary Care Population-Level Initiative.

To describe processes and outcomes of a health system quality improvement initiative designed to reduce opioid-related harms. The initiative was a primary care population-level intervention to reduce high-dose opioid prescribing, which was locally defined as >200 morphine-equivalent mg (MED) daily. We describe the implementation process and report prescribing rates and primary care provider (PCP) attitudes and beliefs before and after implementation. A VA health care system comprising one large, urban teaching hospital and 11 outpatient clinics in surrounding suburban and rural locations. All patients who received any prescription from the outpatient pharmacy (unique pharmacy patients) were included in the population. PCPs at the main hospital were surveyed. Prescribing outcomes were determined from merged VA databases by examining rates of opioid dispensing within 90-day time windows before and after implementation. PCP beliefs and attitudes were evaluated with preimplementation and postimplementation surveys. Following implementation, the number of patients prescribed >200 MED daily decreased from 342 (0.65% of unique pharmacy patients) to 65 (0.12%). Overall, the number of unique pharmacy patients who received at least one opioid prescription within 90 days decreased from 6,942 (13.7%) on April 1, 2011 to 5,981 (11.0%) on October 1, 2014 (13.8% decrease). Most PCPs agreed it was reasonable for the medical center to set a 200 MED limit (76% at baseline and 87% at follow up). Opioid Safety Initiative implementation was associated with a substantial reduction in high-dose opioid prescribing. Factors that contributed to initiative success included leadership support and active clinical pharmacy engagement.