1. VA Implementation Research Seth Eisen, MD, MSc Director Health Services Research and Development (HSR&D) Department of Veterans Affairs Washington, DC

2. VA Implementation Research Environment • Electronic medical record • National databases • Outstanding group of clinical researchers • Research funding programs • Strong academic affiliations • Clinical and research leadership and operations • Large integrated health care delivery system involvement and support

3. QUERI Quality Enhancement Research Initiative

4. QUERI Mission To enhance the quality, outcomes, and efficiency of VA health care by systematically facilitating the implementation of evidence-based research findings into routine clinical practice

5. QUERI’s Six-Step Process • Identify high-risk/high-volume diseases or health problems among veterans, • Identify best practices, • Define existing practice patterns and outcomes across VA, and current variation from best practices, • Identify and implement interventions to promote best practices, • Document that best practices improve outcomes, • Document that outcomes are associated with improved health-related quality of life.

6. QUERI’s Research/Implementation Pipeline Identify Research Area Implement Intervention & Document outcome Identify Best Practice Clinical Research / Guideline Development Implementation Research Implementation Policy, Improved Health Mainstream Health Services Research Assess Existing Practice Phase 1 Pilot Projects Phase 2 Small-Scale Demonstrations Phase 3 Regional Demonstrations Phase 4 “National Rollout”

7. Ischemic Heart Disease Chronic Heart Failure Diabetes Stroke HIV/Hepatitis C Polytrauma and Blast-Related Injuries Spinal Cord Injury Mental Health Substance Use Disorders Nine QUERICoordinating Centers

8. QUERI Centers QUERI Coordinating Centers PT/BRI-QUERI Minneapolis, MN SCI-QUERI Hines, IL DM-QUERI Ann Arbor, MI IHD-QUERI Seattle, WA CHF-QUERI Palo Alto, CA STROKE-QUERI Indianapolis, IN HIV/HEPATITIS C-QUERI Greater Los Angeles MH-QUERI Little Rock, AR SUD-QUERI Houston, TX

9. Funding Sources • QUERI Coordinating Centers - $450,000 Core from Medical Care (~$200k for projects) • Service-Directed Projects (SDP; $900k max) & Rapid Response Projects (RRP; $50k max) funded from Medical Care • VA Investigator-Initiated Research • NIH, AHRQ, RW Johnson

10. QUERI Projects and Impacts • CHF-QUERI decreased hospital readmission rates by up to 10% through patient-centered care coordination. • DM-QUERI improved BP control in veterans with diabetes in VISN 11.

11. QUERI Projects and Impacts cont’d • HIV/Hepatitis-QUERI improved rates of HIV screening, and optimal treatment with antiretroviral drugs. • MH-QUERI improved treatment and outcomes for veterans with depression by implementing collaborative care models.

12. QUERI Projects and Impacts cont’d • SCI-QUERI doubled the rates of pneumonia and influenza vaccine for spinal cord injured veterans. • Stroke QUERI improved quality of post-stroke depression care and produced and evaluated patient information materials on stroke prevention.

13. Challenges • Simultaneous implementation of >1 evidence based best practice • Implementation of treatments in clinically important areas with little evidence based knowledge • “De-implementation” of widely used, non-evidence-based interventions • Transition of implementation to routine patient care • Identification of new QUERI areas

14. Possible New QUERI Areas • “Healthy Behavior”, e.g., weight control, exercise, patient adherence • Cancer • Long-term community care • Simultaneous implementation of several evidence based best practice

15. QUERI Summary • VA provides an outstanding environment for implementation research • QUERI identifies & evaluates the implementation of evidence based best practices, & assists with system-wide adoption • Substantial challenges remain, including how to simultaneously implement several evidence based best practices

16. Essential Resource for Investigators: Online implementation guide: http://www.hsrd.research.va.gov/ queri/implementation/

17. Contact Information: • QUERI Program Manager: Linda.McIvor@va.gov • Implementation Portfolio Manager: Caryn.Cohen@va.gov

18. QUERI: Lessons Learned • Partner leaders and researchers at the start • Apply evidence to a broader range of issues • Increase the emphasis on products needed by the system to improve performance • Add capacity to conduct Implementation Research

19. Promoting Implementation Research: Within and Outside of VA • Sponsorship of Open-Access Implementation Science Journal • QUERI theme issue to be published in 2007 • Work with AHRQ, NIH and CDC to develop review criteria and methodological standards • Active Involvement and Sponsorship of IOM Forum on Science of QI and Implementation • Integrate activities across ORD and with key internal groups (NLB, OQP, PCS, OAA)