Center for Clinical Management Research, VA Ann Arbor Healthcare System
For the second time in two decades, the Veterans Health Administration (VHA) is undergoing major transformation. The VA Strategic Plan directs VHA to become more Veteran-centric, to use technology to better support health care delivery, and to improve appropriateness, safety, and efficiency of care for the 8.1 million Veterans it serves.
In an era of rising healthcare costs and rapid technology advancement, these measures are necessary to VHA’s retaining its status as a model for providing efficient and high-quality care. As healthcare reform broadens choices for citizens, VHA must become a healthcare system where well-informed Veterans choose to obtain their care.
To make these changes, the VA Center for Clinical Management Research (CCMR) is conducting research in three focus areas: (1) finding ways to optimize healthcare decisions while maintaining a focus on patient centeredness; (2) developing and implementing innovative approaches to improve safe clinical care, especially for the most vulnerable, complex, and costly patients; and (3) improving patient outcomes with lower resource expenditures by devising sustained approaches to engage patients and their caregivers in self-management.
Examples of CCMR research conducted each of these three areas in 2016 are provided below.
Much of the work in this area addresses not only how to get patients the proper treatment when they need it, but also on how to ensure that patients do not receive risky and costly treatment when they are at low risk for a disease.
For example, CCMR and U-M investigators in the Center for Bioethics and Social Sciences in Medicine (CBSSM) have demonstrated the feasibility of using a machine-learning risk prediction model to identify patients at high and low risk for chronic hepatitis C (CHC). The use of a risk prediction model to prioritize CHC treatment has the potential to maximize benefit, while minimizing harm and containing costs. Such a model could be of tremendous benefit to VHA, given the large amount of resources currently devoted to pharmaceuticals for the treatment of CHC in Veteran patients. CCMR investigators are hoping to test this model in VHA.
In another study, CCMR investigators are working with the Center for Health Communications Research (CHCR) at the Institute for Healthcare Policy & Innovation (IHPI) to develop, implement, and evaluate a web-based decision support tool for helping VHA primary care providers discuss the risks and benefits of lung cancer screening, based on a patient’s individual risk of developing lung cancer. They will be using an innovative quality improvement program developed by the Institute for Healthcare Improvement to help VA medical centers determine how to incorporate the tool into a busy clinical practice.
CCMR investigators are also developing ways to pinpoint when medical services should be “de-intensified”—reduced, removed, or simply not started when such services are unnecessary, or potentially harmful. For example, recent analyses of VA data have demonstrated opportunities for de-intensifying treatment of older patients with low glucose or blood pressure levels
CCMR has a strong track record of improving care for our most vulnerable, complex, and costly patients, and is currently focused on developing innovative approaches that focus on systems-based solutions for two especially vulnerable patient subgroups: patients with significant mental health problems or substance use disorders, and hospitalized medical patients.
Research on improving care for hospitalized patients produced the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), which specifies indications for peripherally inserted central catheter (PICC) use. Other research completed this past year by the Patient Safety Enhancement Program (PSEP) showed that hospital patients given anti-heartburn drugs have a higher risk of dying, and less than half of U.S. hospitals require flu shots for staff, despite the risk posed to patients. Findings from CCMR’s research on patients with sepsis showed that sepsis survivors are often re-admitted to the hospital for preventable reasons, and mortality among Veterans with severe sepsis has declined, but significant variations in mortality rates across VA hospitals persists. Finally, in a June 2, 2016 New England Journal of Medicine article, CCMR investigators revealed that efforts by the Agency for Healthcare Research and Quality to reduce catheter-associated urinary tract infections (CAUTI) in U.S. hospitals have paid off in the non-ICU setting, as evidenced by a 32% reduction in CAUTI rates.
CCMR research on improving the care of patients with mental health problems or substance use disorders this past year included noteworthy findings on the determinants of opioid overdoses, and on mortality risk from antipsychotic drugs in patients with Parkinson’s Disease and dementia. A new study was initiated to examine the impact of VA antipsychotic reduction efforts on patients with dementia.
New grants to improve care for patients at risk of opioid overdose or at risk for suicide were also funded. Efforts to reduce the risk of opioid overdose will use motivational interviewing plus cognitive behavioral strategies in the primary care setting to provide tailored feedback on risks of opioid use, and to elicit commitment from patients to reduce overdose risk behavior and over-reliance on opioids for pain management.
An intervention for reducing suicidal behavior will target Veterans hospitalized for a recent suicidal crisis who have not yet used the Veterans’ Crisis Line. These patients will be provided with brief, motivational interviewing-based therapy in an effort to increase use of the Crisis Line, thereby decreasing the likelihood of future suicide attempts.
Improving the effectiveness and efficiency of patient self-management and treatment engagement has mainly focused on the development, testing, and implementation of innovative interventions, with a particular emphasis on enhancing patients’ self-management and prevention of chronic conditions. One new line of work is in this area uses theories of behavioral economics to design interventions.
Findings from one such study showed that use of a lottery encouraged patients to screen for colon cancer. New work in this area will use these theories, as well as theories from health psychology, to design interventions to motivate patients to engage in healthy behaviors to prevent type 2 diabetes mellitus.
CCMR investigators participating in the QUICCC (Quality Improvement for Complex Chronic Conditions) partnership with U-M continue their research on the effects of providing automated feedback to non-household family members or friends willing to act as “CarePartners” for supporting patients with their self-management activities. This past year results were published from a study that used this approach for caregivers of VHA patients with chronic heart failure. Findings showed that when CarePartners experienced significant caregiving strain and depression, systematic feedback about their patient-partner decreased those symptoms.
Recently funded research in this focus area is examining the effect of computer-based Cognitive Behavioral Therapy (cCBT) programs for assisting Veterans with management of their depression and with pain management. One new study utilizes peers to promote the use of cCBT for patients with depression. Another study is testing the hypothesis that artificial intelligence-based CBT will result in functional outcomes that are at least as good as standard telephone CBT for patients with chronic pain, while improving patient engagement and satisfaction and reducing costs. The artificial intelligence approach will determine each patient’s personally-tailored treatment plan based on daily feedback via interactive voice response on patients’ physical activity, physical functioning, and CBT skill practice.
All of the above research is taking place in the collaborative environment of IHPI, which enables CCMR research teams to work closely with U-M partners, including the following VA/U-M consortia referenced above:
- VA/U-M Quality Improvement for Complex Chronic Conditions (QUICCC)
- VA/U-M Patient Safety Enhancement Program (PSEP)
- VA/U-M Center for Bioethics and Social Sciences in Medicine (CBSSM)
- VA/U-M Mental Health Services Research