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. Quality Enhancement Research Initiative QUERI

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

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

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

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 contd 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 contd 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)