EvidenceNOW: Virginia Cooperative

EvidenceNOW: Advancing Heart Health in Primary Care is an initiative of the Agency for Healthcare Research and Quality (AHRQ) to transform health care delivery by building a critical infrastructure to help smaller primary care practices improve the heart health of their patients by applying the latest medical research and tools. EvidenceNOW established seven regional cooperatives composed of public and private health partnerships that provide a variety of quality improvement services typically not available to small primary care practices. The goal of this initiative is to ensure that primary care practices have the evidence they need to help their patients adopt the ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure control, Cholesterol management, and Smoking cessation. The initiative also includes an independent national evaluation designed to determine if and how quality improvement support can accelerate the dissemination and implementation of new evidence in primary care.

Cooperative Name: Heart of Virginia Healthcare

Principal Investigator: Anton Kuzel, M.D., M.H.P.E., Virginia Commonwealth University

Cooperative Partners:
Virginia Commonwealth University
Virginia Center for Health Innovation
George Mason University
Community Health Solutions
Health Quality Innovators
National Association for State Health Policy

Geographic Area: Virginia

Project Period: 2015–2018

Region and Population

Virginia has a population of more than 8.4 million people.¹ Heart disease is the second leading cause of death.² Although most of these deaths occur in the populous urban and suburban centers in Northern, Central, and Eastern Virginia, some of the highest age-adjusted death rates due to heart disease can be found in less populous rural areas, including medically underserved areas.³ Like the United States as a whole, Virginia experiences racial, ethnic, and economic disparities in access to care and effectiveness of care for cardiovascular disease (CVD).^4,5

Specific Aims

1. Accelerate the incorporation of patient-centered outcomes research (PCOR) findings (both clinical and organizational) into practice, with an initial focus on cardiovascular health and ABCS.
2. Increase practices' capacity to integrate new PCOR findings on an ongoing basis.
3. Help practices become more efficient and more patient-centered, and help physicians return to spending most of their time caring for patients.

Reach

• Number of Participating Practices: 208
• Practice characteristics
  • Location
    • 68.1 percent urban
    • 23.4 percent rural
    • 8.5 percent suburban
  • Number of Clinicians
    • 5.9 percent solo
    • 60.1 percent 2-5 clinicians
    • 16.5 percent 6-10 clinicians
    • 11.7 percent 11 or more clinicians
    • 5.9 percent unknown
  • Ownership
    • 28.2 percent clinician owned
    • 41.5 percent hospital or health system-owned
    • 9.0 percent FQHC
    • 16.5 percent Other/Multiple
    • 4.8 percent unknown

Note: These preliminary data are provided for illustrative purposes. Numbers are subject to change based on final data analyses. Data courtesy of ESCALATES, the EvidenceNOW independent national evaluator under AHRQ grant number R01HS023940-01. For more information about the national evaluation, visit: www.escalates.org.

Updates on Key Project Components

Support Strategy

The Virginia Cooperative offers practice facilitation in an intensive intervention and coaching phase (3 months) followed by a maintenance phase (9 months), with the following components:

• Expert consultation from practice facilitators and physician faculty to help practices solve specific challenges in quality improvement and practice transformation
• Collaborative learning events to help practices learn and implement PCOR findings and related practice improvements
• An online support center where practices can find and share announcements, ideas, insights, and promising practices. Online resources will include articles, tools, tutorials, and Webinars, plus data on community CVD indicators
• Data feedback and benchmarking based on practices’ reports on multiple dimensions of their experience, including ABCS measures, allowing them to compare their performance to other practices and informing their practice improvement efforts.

Update

Virginia recruited 240 practices, 208 of which are still active. Ninety of these are clinician-owned practices (i.e., independent); 126 are hospital-affiliated. It currently has collected data on the ABCS measures from 124 practices.

The Virginia Cooperative is working with participating practices to develop solutions to make it easier to obtain accurate and timely data from the EHRs. Practice facilitators observe that practices are often navigating competing priorities. Understanding this helps the Cooperative work and communicate with practices more effectively.

Practices seem more willing to spend time on measures that are in some way tied to incentives. Several smaller practices have joined ACOs to increase resources and support to help them compete in a changing health care system.

Evaluation

The Virginia Cooperative is using a stepped-wedge design with three intervention cohorts (3 months each of weekly coaching, plus 9 more months of active support), with practices stratified by geographic region and then randomized to a specific wedge and intervention start date (February, May, or August 2016).

Update

Generating the ABCS metrics for all the population subgroups took more effort than expected.  The Cooperative adopted a wide range of strategies that staff adapted to specific practice needs. The Cooperative developed programming language that helped practices generate measures required by Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF). Staff also wrote and ran custom reports for practices both remotely or onsite and provided coding so that practices could run their own data reports. In some cases, staff obtained de-identified and encrypted continuity of care documents (CCDs) from the EHRs and computed the ABCS metrics for the practices.

The Cooperative has now collected ABCS clinical data from more than 80 percent of active practices. Many of the practices that have not submitted data are part of health systems that have experienced disconnects between quality improvement leaders—who welcomed the EN project—and overburdened IT staff for whom reports linked to payer incentive contracts take higher priority.

Obtaining the target response rate for practice surveys required substantial effort. Practices could respond online via an email with links to a web-based survey instrument or using paper surveys sent by mail (which staff then coded by hand). The Cooperative compensated practices for the time and effort required to complete the surveys.

The Virginia Cooperative looks forward to turning to data analysis of both the clinical and the survey data, and to linking them.

Focus groups and in-depth interviews with a variety of participating practices will be conducted this fall, and staff expect insights to inform hypothesis testing when the quantitative data collection is complete.

Comment From Principal Investigator

Anton Kuzel, M.D., M.H.P.E.

"Our experience confirms the need for primary care practice supports that are practical, guided by practice priorities, and designed to improve practice efficiency and reduce stress.  The other major lesson from this national program is that most EHRs are not ready to provide the kind of information to support pay-for-performance and population health initiatives. EvidenceNOW, although a large project, has only touched a small fraction of the primary care practices in the US; the needs we have discovered require a nationwide response."

Publications and Other Dissemination Activities

The Virginia Cooperative has published one article, made presentations at several national conferences as well as produced a webinar.

Publications:

• Primary care provider burnout: implications for states and strategies for mitigation [National Academy for State Health Policy, 2017]

Presentations:

• Association Between Practice Ownership or Affiliation With Baseline Performance on Addressing Cardiovascular Risk Factors and Capacity for Managing Change in Primary Care: A Heart of Virginia Healthcare Report [NAPCRG, 2017]
• Joy in practice as an enabling strategy for quality improvement in cardiovascular care [SGIM, 2017]
• The Influence of Organizational Readiness to Change on Primary Care Practices’ Training Choices for Quality Improvement [NAPCRG, 2016]

Webinar:

• Primary Care Provider Burnout: What States Need to Know and What They Can Do About It.

References

1. https://www.census.gov/quickfacts/fact/table/VA/PST045216. Accessed August 16, 2017.
2. https://www.cdc.gov/nchs/pressroom/states/VA_2015.pdf. Accessed August 16, 2017.
3. Centers for Disease Control and Prevention. Interactive Atlas of Heart Disease and Stroke. https://nccd.cdc.gov/DHDSPAtlas/Reports.aspx   Accessed August 16, 2017.
4. Virginia Health Equity Report, 2012. Richmond (VA): Virginia Department of Health.; 2012.  http://www.vdh.virginia.gov/health-equity/virginia-health-equity-report/. Accessed August 16, 2017.
5. Centers for Disease Control and Prevention. Interactive Atlas of Heart Disease and Stroke. https://nccd.cdc.gov/DHDSPAtlas/Reports.aspx. Accessed August 16, 2017