Smarter Care Virginia
Study Details
Study Description
Brief Summary
Low-value care is defined as patient care that provides no net benefit to patients in specific clinical scenarios, and it can cause patient harm. Prior research has documented high-rates of low-value care in Virginia, and this work has helped to inspire a Virginia government-sponsored quality improvement initiative to reduce low-value care. Funded by a $2.2 million Arnold Ventures grant, six large health systems in Virginia volunteered to partner with the Virginia Center for Health Innovation (VCHI) to reduce use of seven low-value health services (three preoperative testing measures, two cardiac screening measures, one diagnostic eye imaging measure, and one peripherally inserted central catheter [PICC] measure). These health systems include nearly 7,000 clinicians practicing across more than 1,000 sites. VCHI is implementing a step-wedge cluster-randomized physician peer-comparison feedback quality improvement intervention to reduce the use of these seven low-value services. VCHI will provide education, quality improvement training, and financial resources to each site, and VCHI will use the Milliman MedInsight Health Waste Calculator to create the peer comparison reports using the Virginia all payer claims database (APCD). Of note, the primary purpose of the initiative is to improve quality of care for Virginia residents and this initiative is not being done for research purposes, and step-wedge randomization is done to both ease logistical workload on VCHI and clarify impact of intervention (IRB exempt). Nevertheless, University of California, Los Angeles (UCLA) team plans to rigorously study and publish the impact of this intervention across the state of Virginia, which is why the UCLA team is preregistering the initiative. The UCLA team will use the Virginia APCD to evaluate the impact of the intervention. Because the APCD has a 1 year time-lag of data collection, the initial results of the impact of the intervention will not be available until August 2020 at the earliest.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
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Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Cohort 1: Multicomponent Physician Performance Peer-Comparison Cohort 1 (2 groups): Runs July 2019 - December 2020 - Inova/Signature Parters and Sentara/Sentara Quality Care Network |
Behavioral: Multicomponent Physician Performance Peer-Comparison Feedback Intervention
The intervention will consist of 5 components delivered simultaneously
Clinical Leadership Team: Each site will develop a Clinical Leadership Team (CLT), typically consisting of quality officers, clinician champions, etc. to implement and monitor the intervention
Speaker Series: VCHI will offer the CLTs access to national experts via a CME-approved speaker series and "office hours" to support the intervention.
Education Materials: The CLTs will distribute clinician and consumer education throughout the health systems calling to avoid 7 low-value services.
Clinician Report Cards: VCHI will distribute quarterly customized clinician performance report cards to the CLTs teams using the Milliman Health Waste Calculator and Virginia APCD
Quality improvement training: The intervention will provide the CLTs with in-person quality improvement and clinician performance feedback training, using principles of self-determination theory, and will include monthly check-in calls
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| Cohort 2: Multicomponent Physician Performance Peer-Comparison Cohort 2 (2 groups): Runs November 2019 - April 2021 - Ballad Health and Carilion Clinic |
Behavioral: Multicomponent Physician Performance Peer-Comparison Feedback Intervention
The intervention will consist of 5 components delivered simultaneously
Clinical Leadership Team: Each site will develop a Clinical Leadership Team (CLT), typically consisting of quality officers, clinician champions, etc. to implement and monitor the intervention
Speaker Series: VCHI will offer the CLTs access to national experts via a CME-approved speaker series and "office hours" to support the intervention.
Education Materials: The CLTs will distribute clinician and consumer education throughout the health systems calling to avoid 7 low-value services.
Clinician Report Cards: VCHI will distribute quarterly customized clinician performance report cards to the CLTs teams using the Milliman Health Waste Calculator and Virginia APCD
Quality improvement training: The intervention will provide the CLTs with in-person quality improvement and clinician performance feedback training, using principles of self-determination theory, and will include monthly check-in calls
|
| Cohort 3: Multicomponent Physician Performance Peer-Comparison Cohort 3 (2 groups): Runs March 2020 - August 2021 - Health Care Associates Virginia/Virginia Care Partners and Virginia and Commonwealth University Health System |
Behavioral: Multicomponent Physician Performance Peer-Comparison Feedback Intervention
The intervention will consist of 5 components delivered simultaneously
Clinical Leadership Team: Each site will develop a Clinical Leadership Team (CLT), typically consisting of quality officers, clinician champions, etc. to implement and monitor the intervention
Speaker Series: VCHI will offer the CLTs access to national experts via a CME-approved speaker series and "office hours" to support the intervention.
Education Materials: The CLTs will distribute clinician and consumer education throughout the health systems calling to avoid 7 low-value services.
Clinician Report Cards: VCHI will distribute quarterly customized clinician performance report cards to the CLTs teams using the Milliman Health Waste Calculator and Virginia APCD
Quality improvement training: The intervention will provide the CLTs with in-person quality improvement and clinician performance feedback training, using principles of self-determination theory, and will include monthly check-in calls
|
Outcome Measures
Primary Outcome Measures
- Percentage of participants with low-value utilization across the 7 low-value care measures [36 months]
The 7 measures are defined using evidenced-based guidelines such as the USPSTF, American College of Cardiology, Choosing Wisely, among other guidelines. The primary measure is a global percentage of use among eligible patients across the 7 measures (see eligibility criteria for each measure-specific denominator): Preoperative laboratory testing Preoperative EKGs, chest x-rays, and pulmonary function testing Preoperative cardiac imaging/stress testing Annual EKG/other cardiac screening for low-risk adults Cardiac stress imaging/cardiac imaging in low-risk adults Diagnostic eye imaging in low-risk patients Peripherally inserted central catheters in stage 3-5 chronic kidney disease patients without consulting nephrology UCLA statisticians will independently assess these measures using the Virginia APCD, which includes paid claims for Commercial, Medicaid, Medicare insured patients, and includes demographics, procedure/diagnostic codes.
Secondary Outcome Measures
- Percentage participants with high-value utilization across the 7 measures (e.g., balancing measures) [36 months]
These balancing measures will assess the use of high-value services. For example, the UCLA team will assess whether symptomatic (e.g., chest pain) patients continue to receive testing (e.g., EKGs) prior to low-risk surgery, or whether patients with eye disease continue to receive eye imaging, etc.
- Percentage of participants with adverse events (e.g., peri-operative medical complications) [36 months]
While VCHI, the UCLA team, and health systems do not expect adverse events (AEs) to increase in this evidenced-based quality improvement initiative, the UCLA team will monitor for them. AEs will be measure specific. For example, patients with preoperative visits will be evaluated for 30 day peri/post-operative medical complications (e.g., myocardial infarction). Patient eligible to receive cardiac screening (and do not receive it) will be evaluated for 30-day myocardial infarction diagnoses and hospitalization rates. Patients eligible to receive eye imaging and do not receive it will be evaluated for 1-year eye disease progression or new diagnosis rates. Patients eligible to receive a PICC line and do not will be evaluated for 30-day readmission rates. Each local health system QI team will also be provided education on how careful, nuanced attention to guidelines can reduce the risk of potential AEs.
- Total costs (estimates from percent effort of clinical leadership team, utilization trends [36 months]
The cost analysis will estimate costs based on changes in utilization over time using costs as defined by the total amount paid to each provider (including out-of-pocket costs) available in the Virginia APCD. The UCLA team will also estimate the percent effort of each member of the clinical leadership team during the study time-frame to estimate investment costs. These latter data will be obtained via surveys and/or interviews of the clinical leadership teams.
Eligibility Criteria
Criteria
Inclusion Criteria
All adult patients (aged 18 or older) at each of the six health systems who are at risk for receiving low-value care across each of the seven measures.
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For preoperative testing, eligible patients include those with a health system evaluation and management visits 30 days prior to low-risk surgery.
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For eye imaging, eligible patients will be patients with evaluation and management visits with a health system ophthalmologist/optometrist.
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For cardiac screening, eligible patients are patients with an ambulatory evaluation and management visit (all specialties).
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For the PICC line measure, eligible patients would include hospitalized patients.
Exclusion Criteria
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Patients under the age of 18.
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Patients who do not meet the above criteria.
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Patients who do not receive care at each of the six health systems.
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | University of California, Los Angeles | Los Angeles | California | United States | 90024 |
Sponsors and Collaborators
- University of California, Los Angeles
Investigators
None specified.Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- 75486025