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BMC Neurology
Published in: BMC Neurology 1/2019

Open Access 01-12-2019 | Care | Study protocol

The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods

Authors: D. M. Bravata, L. J. Myers, B. Homoya, E. J. Miech, N. A. Rattray, A. J. Perkins, Y. Zhang, J. Ferguson, J. Myers, A. J. Cheatham, L. Murphy, B. Giacherio, M. Kumar, E. Cheng, D. A. Levine, J. J. Sico, M. J. Ward, T. M. Damush

Published in: BMC Neurology | Issue 1/2019

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Abstract

Background

Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles.

Methods

This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability.

Discussion

PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines.

Trial registration

clinicaltrials.​gov: NCT02769338 [May 11, 2016].
Literature
1.
Hysong SJ, Francis J, Petersen LA. Motivating and engaging frontline providers in measuring and improving team clinical performance. BMJ Quality Safety. 2019.
2.
3.
Davies L, Donnelly KZ, Goodman DJ, Ogrinc G. Findings from a novel approach to publication guideline revision: user road testing of a draft version of SQUIRE 2.0. BMJ Quality Safety. 2016;25(4):265–72.PubMedCrossRef
4.
5.
Easton J, Saver J, Albers G, et al. Definition and evaluation of transient ischemic attack. Stroke. 2009;40(6):2276–93.PubMedCrossRef
6.
Johnston KC, Connors AF, Wagner DP, Knaus WA, Wang XQ, Haley EC. A predictive risk model for outcomes of ischemic stroke. Stroke. 2000;31:448–55.PubMedCrossRef
7.
Johnston S. Short-term prognosis after a TIA: a simple score predicts risk. Cleve Clin J Med. 2007;74(10):729–36.PubMedCrossRef
8.
9.
Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160–236.PubMedCrossRef
10.
Lavallée P, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6(11):953–60.PubMedCrossRef
11.
Luengo-Fernandez R, Gray A, Rothwell P. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison. Lancet Neurol. 2009;8(3):235–43.PubMedCrossRef
12.
Giles M, Rothwell P. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007;6(12):1063–72.PubMedCrossRef
13.
O'Brien EC, Zhao X, Fonarow GC, et al. Quality of care and ischemic stroke risk after hospitalization for transient ischemic attack: findings from get with the guidelines-stroke. Circ Cardiovasc Qual Outcomes. 2015;8(6 Suppl 3):S117–24.PubMedCrossRef
14.
Bravata D, Myers L, Arling G, et al. The quality of Care for Veterans with transient ischemic attack and minor stroke. JAMA Neurology. 2018;75(4):419–27.PubMedPubMedCentralCrossRef
15.
Damush TM, Miech EJ, Sico JJ, et al. Barriers and facilitators to provide quality TIA care in the veterans healthcare administration. Neurology. 2017;89(24):2422–30.PubMedPubMedCentralCrossRef
16.
Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.PubMedPubMedCentralCrossRef
17.
Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581–629.PubMedPubMedCentralCrossRef
18.
Atkins D, Kilbourne AM, Shulkin D. Moving from discovery to system-wide change: the role of research in a learning health care system: experience from three decades of health systems research in the veterans health administration. Annu Rev Public Health. 2017;38:467–87.PubMedCrossRef
19.
Kizer KW, Dudley RA. Extreme makeover: transformation of the veterans health care system. Annu Rev Public Health. 2009;30:313–39.PubMedCrossRef
20.
Hagg H, Workman-Germann J, Flanagan M, et al. Implementation of systems redesign: approaches to spread and sustain adoption. Rockville, MD (USA): Agency for Healthcare Research and Quality; 2008.
21.
Redfern J, McKevitt C, Wolfe CD. Development of complex interventions in stroke care: a systematic review. Stroke. 2006;37(9):2410–9.PubMedCrossRef
22.
Craig P, Dieppe P, Macintyre S, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ (Clinical research ed). 2008;337:a1655.
23.
Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health. BMJ (Clinical research ed). 2000;321(7262):694–6.CrossRef
24.
Medical Research Council (MRC). A Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Health. London2000.
25.
Bosworth H, Olsen M, Grubber J, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med. 2009;151(10):687–95.PubMedPubMedCentralCrossRef
26.
Bosworth H, Powers B, Olsen M, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med. 2011;171(13):1173–80.PubMedCrossRef
27.
Ranta A, Dovey S, Weatherall M, O'Dea D, Gommans J, Tilyard M. Cluster randomized controlled trial of TIA electronic decision support in primary care. Neurology. 2015;84(15):1545–51.PubMedCrossRef
28.
Rothwell P, Giles M, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet (London, England). 2007;370(9596):1432–42.CrossRef
29.
30.
Bravata DM, Myers LJ, Cheng E, et al. Development and Validation of Electronic Quality Measures to Assess Care for Patients With Transient Ischemic Attack and Minor Ischemic Stroke. Circ Cardiovasc Qual Outcomes. 2017;10(9).
31.
Ayers LR, Beyea SC, Godfrey MM, Harper DC, Nelson EC, Batalden PB. Quality improvement learning collaboratives. Qual Manag Health Care. 2005;14(4):234–47.PubMedCrossRef
32.
33.
Mdege ND, Man MS, Taylor Nee Brown CA, Torgerson DJ. Systematic review of stepped wedge cluster randomized trials shows that design is particularly used to evaluate interventions during routine implementation. J Clin Epidemiol. 2011;64(9):936–48.PubMedCrossRef
34.
Curran G, Bauer M, Mittman B, Pyne J, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–26.PubMedPubMedCentralCrossRef
35.
Barker D, McElduff P, D'Este C, Campbell MJ. Stepped wedge cluster randomised trials: a review of the statistical methodology used and available. BMC Med Res Methodol. 2016;16:69.PubMedPubMedCentralCrossRef
36.
Li J, Zhang Y, Myers LJ, Bravata DM. Power calculation in stepped-wedge cluster randomized trial with reduced intervention sustainability effect. J Biopharm Stat. 2019;29(4):663–74.PubMedCrossRef
37.
Bravata DM, Myers LJ, Reeves M, et al. Processes of care associated with risk of mortality and recurrent stroke among patients with transient ischemic attack and nonsevere ischemic stroke. JAMA Netw Open. 2019;2(7):e196716.PubMedPubMedCentralCrossRef
38.
Man S, Zhao X, Uchino K, et al. Comparison of acute ischemic stroke care and outcomes between comprehensive stroke centers and primary stroke centers in the United States. Circ Cardiovasc Qual Outcomes. 2018;11(6):e004512.PubMedPubMedCentralCrossRef
39.
Fonarow GC, Reeves MJ, Smith EE, et al. Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke. Circ Cardiovasc Qual Outcomes. 2010;3(3):291–302.PubMedCrossRef
40.
Li J, Zhang Y, Myers L, Bravata D. Power Calculation in Stepped-Wedge Cluster Randomized Trial with Reduced Intervention Sustainability Effect. J Biopharm Stat. 2019;In Press.
41.
Hamilton A, Brunner J, Cain C, et al. Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women’s health primary care. TBM. 2017;7(3):478–85.
42.
Ritchie MJ, Parker LE, Edlund CN, Kirchner JE. Using implementation facilitation to foster clinical practice quality and adherence to evidence in challenged settings: a qualitative study. BMC Health Serv Res. 2017;17(1):294.PubMedPubMedCentralCrossRef
43.
Jung TST, Davies HTO, Bower P, Whalley D, et al. Instruments for exploring organizational culture: a review of the literature. Public Adm Rev. 2009;69:1087–96.CrossRef
44.
45.
Miech E. The GO Score: A New Context-Sensitive Instrument to Measure Group Organization Level for Providing and Improving Care. Washington DC.2015.
46.
Rattray NA, Damush TM, Luckhurst C, Bauer-Martinez CJ, Homoya BJ, Miech EJ. Prime movers: advanced practice professionals in the role of stroke coordinator. J Am Assoc Nurse Pract. 2017;29(7):392–402.PubMed
47.
IOM. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press; 2013.
48.
President’s Council of Advisors on Science and Technology. Realizing the full potential of health information technology to improve healthcare for Americans: the path forward, Report to the President. In. Washington, DC 2010:1–108.
49.
Etheredge LM. A rapid-learning health system. Health Aff. 2007;26(2):w107–18.CrossRef
50.
Tuti T, Nzinga J, Njoroge M, et al. A systematic review of electronic audit and feedback: intervention effectiveness and use of behaviour change theory. Implement Sci. 2017;12(1):61.PubMedPubMedCentralCrossRef
51.
Basaraba JE, Picard M, George-Phillips K, Mysak T. Pharmacists as care providers for stroke patients: a systematic review. Can J Neurol Sci. 2018;45(1):49–55.PubMedCrossRef
Metadata
Title
The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods
Authors
D. M. Bravata
L. J. Myers
B. Homoya
E. J. Miech
N. A. Rattray
A. J. Perkins
Y. Zhang
J. Ferguson
J. Myers
A. J. Cheatham
L. Murphy
B. Giacherio
M. Kumar
E. Cheng
D. A. Levine
J. J. Sico
M. J. Ward
T. M. Damush
Publication date
01-12-2019
Publisher
BioMed Central
Published in
BMC Neurology / Issue 1/2019
Electronic ISSN: 1471-2377
DOI
https://doi.org/10.1186/s12883-019-1517-x

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