Maximizing Impact
VA Research by Walid Gellad, MD, MPH, Leads to High Impact Implementation To Improve Safety of Medications, Including Opioids, For Veterans
The U.S. Department of Veterans Affairs (VA) and Centers for Medicare & Medicaid Services (CMS) recently announced an agreement that greatly improves drug safety monitoring of prescriptions, including opioids. The agreement will give VA the ability to monitor medical prescriptions issued outside the VA through Medicare Part D.
This landmark policy was propelled by VA-funded research led by Walid Gellad, MD, MPH, and stands as a major achievement and example of research implementation to improve care for Veterans who are also covered by Medicare Part D. Dr. Gellad's work showed the risks of dual VA/Medicare prescription coverage and revealed how many medications are missed for Veterans when only looking at VHA data.
VA currently has a robust system in place for medication surveillance to ensure safe use by Veteran patients and the ability to analyze patient outcomes. This new agreement will enable VA to incorporate up-to-date Medicare prescription information into its safety surveillance operations. By incorporating prescriptions dispensed through Medicare, VA providers have access to more accurate information about the medications used by its patients.
More than 5 million Veterans receive prescription medications through VA. With the creation of the Medicare Part D benefit, Veterans dually enrolled in VA and Medicare have access to prescription benefits through both VA and Medicare, creating the potential for adverse drug interactions, duplication of use and greater risk of adverse drug events, including overdoses.
Gellad's research is focused on developing more effective prescribing practices for physicians and Veterans, and improving the way the VA health care system functions—in terms of better access to medications and safer prescribing practices. His research has been funded in large part through VA's Health Services Research and Development service.
Read more about this ground-breaking work:
- Patterns of opioid prescriptions received prior to unintentional prescription opioid overdose death among Veterans
- Dual Receipt of Prescription Opioids From the Department of Veterans Affairs and Medicare Part D and Prescription Opioid Overdose Death Among Veterans
- 'Dual use' Veterans may be at risk for unsafe opioid use
- Medicare and Medicaid Services join to strengthen safety surveillance for medications issued to Veterans
Dr. Gellad s a primary care physician and health services researcher with the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System. He is also Professor of Medicine and Director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh. He is considered a national expert on prescription drug pricing and patient medication adherence.
FY 2018 COIN-Developed Health Services Research Methods and Products
Remote Veterans Apnea Management Platform (REVAMP)
CHERP Core Investigator Samuel T. Kuna, MD applied findings from his VA HSR&D study (IIR 04-021) to develop REVAMP, a Veteran- and provider-facing interactive web platform that enables remote diagnosis and management of obstructive sleep apnea (OSA) for rural and other Veterans to improve their access to specialty care. Building on the clinical award from the VHA Innovation Program to implement REVAMP, Dr. Kuna subsequently secured HSR&D funding (IIR 12-409) to conduct a prospective, randomized intervention trial comparing REVAMP management to in-person care for Veterans with OSA.
Launched in FY17 at 10 pilot sites, REVAMP was implemented in 49 VA Medical Centers (VAMCs) in FY18 and is on track for VA-wide roll-out by the end of FY19. In partnership with the Office of Rural Health, Dr. Kuna and his team are also working with Hub and Spoke Sleep Centers that use REVAMP to link VAMCs with sleep programs to rural VAMCs and Community-Based Outpatient Clinics.
REVAMP was selected as one of 30 finalists for the American Council for Technology and Industry Advisory Council (ACT-IAC) Igniting Innovation 2017 Showcase and Awards.
IMPaCT Community Health Worker Intervention
Health systems across the US are struggling to reduce health care costs while providing high-quality care to the sickest, most vulnerable patients. Other countries have responded to similar challenges by expanding their use of community health workers (CHWs), frontline health workers who are trusted members of the community and share life experiences with their patients. CHWs are inexpensive and have shown to be effective in improving the health outcomes of marginalized populations.
US health systems have lagged in utilizing CHWs due to the absence of a scientifically-proven, standardized CHW model that is easy to implement and utilize. Seeking to close that gap, Judith Long, MD and colleagues developed IMPaCT (Individualized Management for Patient-Centered Targets), an exportable model for care in which CHWs provide structured advocacy, social support, and navigation to help low socioeconomic status patients achieve their health goals.
IMPaCT website: http://chw.upenn.edu/
Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: a randomized clinical trial. JAMA Intern Med. 2018 Dec 1;178(12):1635-1643. PMID: 30422224Adoption by VA Facilities, National Program Office/Initiative or Frontline Providers:
The IMPaCT CHW has been adopted by CMCVAMC and the Penn Health System as part of their respective system-wide population health management strategies for high-risk, socially disadvantaged patients. With support from QUERI and the Diffusion of Excellence team, Dr. Long is working with the Iowa City VAMC and two other VAMCs to implement similar CHW interventions at those facilities.
IMPaCT has been delivered to nearly 7,000 patients in the Philadelphia region (including 270 Veterans at CMCVAMC), and an open-source toolkit including intervention manuals has been accessed by >1,000 organizations across the country. It has also been adopted by Keystone First — the largest Medicaid managed care provider in southeast Pennsylvania — for delivery to patients. The team is currently providing implementation assistance to eight partner organizations, including Partners HealthCare and UPMC Health Plan.
Honors or Awards, Patents or Licenses Agreements Received:
The intervention was recognized as a Gold Status practice as part of the VHA Shark Tank competition. Findings from this work were disseminated by high-impact news outlets, including NPR, the Philadelphia Inquirer, and the New York Times.
Dr. Shreya Kangovi and collaborators, including Dr. Long were recently awarded a three-year $1.4 million PCORI Dissemination & Implementation grant to adapt and implement the IMPaCT (Individualized Management of Patient-Centered Targets) Community Health Worker model in three new healthcare organizations: the Pittsburgh VA Medical Center, the Wilmington VA Medical Center, and Blue Cross Blue Shield North Carolina's Medicaid program. The study team will assess program reach, fidelity, and stage of implementation achieved for each site, as well as effects on hospitalizations among over 4500 patients receiving the IMPaCT intervention.
Risk Analysis Index Frailty Measurement Tool
The Risk Analysis Index (RAI) is a 14-item instrument developed and validated by Daniel Hall, MD, MDiv, MHS and colleagues to measure surgical frailty prospectively using a clinical questionnaire (RAI-C) or retrospectively using variables from standardized surgical quality improvement databases such as the VA or American College of Surgeons National Surgical Quality Improvement Programs (RAI-A).
The related Online Multi-Mode Frailty Assessment enables users to calculate the RAI concurrently with other measures such as the Edmonton Frailty Scale, Hopkins Frailty Score, grip strength, gait speed, mini-Cog and Timed Up and Go.
Development and initial validation of the Risk Analysis Index for measuring frailty in surgical populations. JAMA Surg. 2017 Feb 1;152(2):175-182. PMID: 27893030Adoption by VA Facilities, National Program Office/Initiative or Frontline Providers:
The RAI and Multi-Mode Frailty Assessment tools are currently in use at the Pittsburgh, Atlanta, Omaha, Indianapolis, and Minneapolis VA Medical Centers and accessible throughout VA through the Online RAI Consortium quality improvement initiative based at VAPHS. In addition to being adopted by five VA Medical Centers, this tool was also implemented at all hospitals across the University of Pittsburgh Medical Centers (UPMC) enterprise, with >150,000 preoperative assessments to date. In addition, Dr. Hall's colleagues from Spain and Argentina have translated the RAI into Spanish and are validating its use in local populations.
VHA Equity Explorer Prototype
Health equity has long been a priority for the Veterans Health Administration. To address disparities, Network and Medical Directors must first know which Veteran groups, or combination of groups are most at risk for poor outcomes in the patient populations they serve. The VHA Equity Explorer, developed by Leslie Hausmann, PhD in partnership with the VA Innovators Network and Office of Health Equity, is an interactive data visualization tool that displays how key quality measures compare across Veteran subgroups defined by characteristics linked with relative social or economic disadvantage (e.g., race/ethnicity, sex, geographic location etc.), alone and in combination, at national, regional and local levels.
Adoption by VA Facilities, National Program Office/Initiative or Frontline Providers:
Led by Dr. Hausmann, in 2013, VISN4 developed a dashboard that used patient-level data from a regionally managed data warehouse to compare outpatient quality measures by Veteran sex and race. This dashboard and supporting infrastructure supported a year-long quality improvement effort to reduce disparities in hypertension. The project garnered national attention, and other VISNs have sought advice on building similar tools to support their own data-driven quality improvement projects. In FY18, the VA Innovator's Network awarded Dr. Hausmann pilot funding to further develop an interactive dashboard prototype to examine disparities in the quality of outpatient care at regional and national levels.
Development of this prototype led to an FY19 partnership with the VHA Office of Health Equity (OHE), who recognized this product as directly aligned with the goals of the Data, Research, and Evaluation component of the VHA Health Equity Action Plan. In operational work supported by OHE, Dr. Hausmann will obtain stakeholder input and apply human-centered design principles to refine the tool and begin testing it in the field. Anticipated outputs of this project include a white paper summarizing recommendations for creation of the dashboard, and how equity reporting tools could be utilized in the field.
Toolkit for Patient Engagement in Patient Aligned Care Teams (PACT)
Led by Judith Long, MD and Rachel Werner, MD, PhD, the VISN4 Center for the Evaluation of Patient Aligned Care Teams (CEPACT) published online tools on the CEPACT web site detailing specific patient engagement practices and resources for clinical care teams. These tools were developed through extensive interviews with VA staff at facilities in VISN4 and nationwide to gather best practices to engage VA patients in their care. A panel of VA staff and Veterans consulted with CEPACT staff to select the most feasible tools to be implemented.
The Patient Engagement Practices Toolkit and Patient Engagement Resources are available at https://www.prevention.va.gov/For_Clinicians/PE_Practices/pe-toolkit.asp.
Improving patient-centered care: how clinical staff overcome barriers to patient engagement at the VHA. Med Care. 2018 Dec;56(12):1009-1017. PMID: 30383571 Creating a toolkit to reduce disparities in patient engagement. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S59-S69. PMID: 28806367Adoption by VA Facilities, National Program Office/Initiative or Frontline Providers:
Facilities across VISN4 are currently implementing patient engagement practices from the toolkit. CEPACT is monitoring and tracking their progress through ongoing calls and meetings.
The effectiveness of the toolkit in improving patient engagement within VISN4 will be evaluated in the coming year. Based on the findings of the evaluation, a refined toolkit will subsequently be distributed nationally.
