1. SUBSTANCE USE DISORDERS Using the Quality Improvement Process to Implement VA/DoD Guidelines SUBSTANCE USE DISORDERS

2. Why Care About Guidelines? Practice lags behind published evidence regarding what worksPractice lags behind published evidence regarding what works Unacceptable variation in practiceUnacceptable variation in practice Examples:Examples: –Smoking cessation in addiction treatment –Pharmacotherapy of alcohol dependence –Treatment of opioid dependence

3. Why Care About Guidelines? This means that:This means that: –Where you are treated will determine the quality of treatment you receive –Our patients are not receiving up- to-date treatment –The outcomes achieved are less than is possible

4. How would you feel if … you got a radical mastectomy when a lumpectomy would give the same result?you got a radical mastectomy when a lumpectomy would give the same result? your doctor failed to prescribe a medication that could prevent relapse of your heart disease?your doctor failed to prescribe a medication that could prevent relapse of your heart disease?

5. How would you feel if… you knew that your provider didn’t even know about new treatments? your provider knew that multiple studies showed that a new treatment was safe and effective, but said, “I don’t believe in it”? What if it meant that you died 10 years earlier than you would have otherwise? What if you would have received that treatment if you had been in another VISN?

6. Why Don’t We Implement Evidence Based Practices? Lack of timeLack of time Lack of knowledge and skillsLack of knowledge and skills Lack of belief in the evidenceLack of belief in the evidence TraditionTradition Lack of institutional supportLack of institutional support Pharmacy barriersPharmacy barriers

7. Why Don’t We Implement Evidence Based Practices? Peers do not support changePeers do not support change Patient preferencePatient preference System makes it hard to changeSystem makes it hard to change No incentive to changeNo incentive to change Hard to do aloneHard to do alone

8. Examples in VHA

9. Opportunities 43% 31% 39%

10. Opioid Agonist Therapy Methadone, LAAM, buprenorphine treatment for opioid dependenceMethadone, LAAM, buprenorphine treatment for opioid dependence Very strong evidence baseVery strong evidence base Highly cost effective (Barnett et al, 2000)Highly cost effective (Barnett et al, 2000) Yet…Yet…

11. Opioid Agonist Therapy Only about ¼ of veterans with a diagnosis of opioid dependence received opioid agonist therapy in 1999Only about ¼ of veterans with a diagnosis of opioid dependence received opioid agonist therapy in 1999 6/22 (27%) of networks have no OAT6/22 (27%) of networks have no OAT This includes 8 of the 25 largest metro areas in the country (32%).This includes 8 of the 25 largest metro areas in the country (32%).

12. The QI Process: A Possible Solution? All VA health care facilities use QIAll VA health care facilities use QI – Staff are familiar with it – Hospital infrastructure to support it – JCAHO Accreditation requires it

13. The QI Process: A Possible Solution? Structured process to:Structured process to: – Identify areas needing improvement – Develop strategies for change – Measure results – Interpret outcome and revise

14. The QI Process: A Possible Solution? Usually used to improve clinical operationsUsually used to improve clinical operations Examples:Examples: – Improve efficiency of intake process – Improve program retention – Decrease error rates

15. The QI Process: A Possible Solution? Involves a team of cliniciansInvolves a team of clinicians Change from the ground upChange from the ground up Based in realityBased in reality Incorporates patient preferencesIncorporates patient preferences

16. Applying QI to Guideline Implementation Identify areas where:Identify areas where: –A good evidence base exists defining effective therapy –There appears to be variation across staff members in application –It is likely that current practice is at substantial variance from evidence- based practices

17. Applying QI to Guideline Implementation Single practice or treatment focusSingle practice or treatment focus Clearly definedClearly defined MeasurableMeasurable Linked to outcomesLinked to outcomes ImportantImportant

18. Applying QI to Guideline Implementation Maximize chance of success byMaximize chance of success by –Choosing treatment over which you have more control –Choosing treatment that has a greater consensus

19. The PDSA Model of QI Plan Act Study Do PDSA is a common form of QI. PDSA means: PDSA is a common form of QI. PDSA means:

20. Plan During the Plan phase, staff examine evidence and decide what areas of the program to address.During the Plan phase, staff examine evidence and decide what areas of the program to address. The Plan phase ends with a decision to collect data about your current practices.The Plan phase ends with a decision to collect data about your current practices.

21. Plan: Example Dr. James Olson, the program coordinator, convenes a team to implement guidelines.Dr. James Olson, the program coordinator, convenes a team to implement guidelines. The group examines the VA/DOD SUD guideline to identify practices with a strong evidence base.The group examines the VA/DOD SUD guideline to identify practices with a strong evidence base.

22. Plan: Example They decide to focus on naltrexone treatment for alcohol dependence because:They decide to focus on naltrexone treatment for alcohol dependence because: –Very strong evidence base –Meta-analysis showed consistent effect –Very low rate of implementation in program

23. Plan: Example The group discusses possible reasons for the low implementation rate:The group discusses possible reasons for the low implementation rate: – Lack of belief in effectiveness – Expense – Poor compliance

24. Plan: Example –Lack of experience using pharmacotherapy to treat alcohol dependence –Low demand by patients –Poor compliance

25. Do Once program staff agree to examine current practices, they enter the Do phase.Once program staff agree to examine current practices, they enter the Do phase. Baseline data are collected on current practices in the clinic.Baseline data are collected on current practices in the clinic. The purpose is to compare clinic and evidence-based practices.The purpose is to compare clinic and evidence-based practices.

26. Do: Example They examine their records for the past 6 months, and find that 5% of their patients with alcohol dependence receive naltrexone.They examine their records for the past 6 months, and find that 5% of their patients with alcohol dependence receive naltrexone. They also find that physicians and counselors vary considerably in their use of naltrexone.They also find that physicians and counselors vary considerably in their use of naltrexone.

27. Study The Study phase begins with analysis of the baseline data.The Study phase begins with analysis of the baseline data. Program staff identify aspects of practice they wish to bring closer to evidence-based practices.Program staff identify aspects of practice they wish to bring closer to evidence-based practices. Based on the data, staff set a goal for change.Based on the data, staff set a goal for change.

28. Study: Example The group sets a goal that 80% of appropriate patients receive a recommendation for naltrexone.The group sets a goal that 80% of appropriate patients receive a recommendation for naltrexone.

29. Act Once a goal is defined, programs enter the Act phase in which they plan and implement a strategy for change.Once a goal is defined, programs enter the Act phase in which they plan and implement a strategy for change. Measurement of practices continues while change is implemented.Measurement of practices continues while change is implemented. At the end of the Act phase, the data are compared to baseline.At the end of the Act phase, the data are compared to baseline.

30. Act: Example The QI group develops strategies to address perceived barriers.The QI group develops strategies to address perceived barriers. For example, they address the lack of belief in effectiveness, lack of familiarity, and lack of experience through education.For example, they address the lack of belief in effectiveness, lack of familiarity, and lack of experience through education. The develop a protocol to identify, assess, and treat appropriate patients.The develop a protocol to identify, assess, and treat appropriate patients.

31. Plan Programs re-enter the Plan phase to determine if their original change has been effective and plan for a new PDSA cyclePrograms re-enter the Plan phase to determine if their original change has been effective and plan for a new PDSA cycle PDSA Cycles should be:PDSA Cycles should be: – Multiple – Repeated – Short (3 months)

32. Plan: Example After 3 months, the group examines the success of the initiative:After 3 months, the group examines the success of the initiative: –46% of appropriate patients received a recommendation for naltrexone, and 38% filled a prescription for it. –Staff are much more knowledgeable.

33. Plan If the original goal has not been met:If the original goal has not been met: – Examine barriers to change – Develop additional strategies – Begin a new PDSA cycle

34. Plan: Example The result, while a big improvement, fell short of the goalThe result, while a big improvement, fell short of the goal Barriers identified include:Barriers identified include: –Poor patient compliance –Some staff members still telling patients not to take naltrexone –Delays in the protocol due to long appt waits for physician

35. Plan: Example The group decides to:The group decides to: –Develop patient education resources regarding naltrexone. –Initiate one-to-one sessions with staff members to determine basis for resistance. –Physician agrees to see pts immediately for naltrexone prescription.

36. Plan If the original goal has been met:If the original goal has been met: –Congratulations! –Review data pertaining to other practices –Select a new goal –Begin a new PDSA cycle

37. Plan: Example After another two PDSA cycles, 72% of appropriate patients received a prescription for naltrexone.After another two PDSA cycles, 72% of appropriate patients received a prescription for naltrexone. The group began to identify other areas for the next group of PDSA cycles.The group began to identify other areas for the next group of PDSA cycles.

38. That’s why it’s called continuous quality improvement.