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Center for Health Equity Research and Promotion

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Maximizing Impact

CHERP investigators have partnered with VA clinical and operations leaders on several initiatives to improve the quality and equity of health care for vulnerable Veteran populations. CHERP investigators conduct high impact research to improve the quality, safety, and value of medication therapy. Their work also contributes to the advancement of the field of behavioral intervention/implementation science. A selection of high impact system improvements and publications are described below.

VISN4 Hypertension Racial Disparity Reduction Initiative

CHERP investigators (Hausmann, Fine, Long, Mor, Burkitt) partnered with VISN4 network and facility leaders and informatics staff to compare 19 VA quality performance measures between blacks and whites in VISN4 and created a novel Health Equity Dashboard (HED) to report these measures stratified by race (i.e., black and white) for all 10 VA Medical Centers in VISN4. In FY13 HED data revealed significant VISN-wide racial disparities in blood pressure control among hypertensive patients, with more white Veterans achieving blood pressure control than black Veterans (81.3% vs. 70.7%; p<0.001).Larger proportions of blacks had uncontrolled blood pressure (>140/90) compared to whites at all VISN4 facilities, with racial differences in control ranging from 2.9% to 14.6% lower in blacks VISN4 has now implemented a network-wide quality improvement initiative to reduce racial disparities in blood pressure control for Veterans with hypertension. Each VISN4 facility has been charged to develop and implement an action plan to improve blood pressure control and reduce racial disparities among hypertensive Veterans they serve. In FY14, CHERP will partner with the Office of Health Equity (OHE) to conduct rigorous evaluation of this initiative to inform future VA-wide efforts to improve the quality and equity of health care for Veterans with hypertension and other common medical conditions

Cultural Competency Training for VA Patient Aligned Care Teams

OHE is partnering with Dr. Hausmann to pilot test a novel cultural competency training program to educate Patient Aligned Care Teams (PACTs) about unconscious bias and ways to prevent unconscious bias from negatively affecting patient care. The training program was developed by OHE education specialists with input from an advisory panel comprising education, research (including Dr. Hausmann), and leadership representatives from VA sites where the program is currently being tested. To date, cultural competency training has been provided in 9 PACTs across 3 sites. The impact of the training program on PACT member attitudes about cultural competency and unconscious bias is being assessed by Dr. Hausmann and CHERP colleagues through baseline and follow-up assessments. In addition, data from the Survey of Healthcare Experiences of Patients for patients who received care from the trained and untrained PACTs before and after training occurred will be assessed to determine the impact of the program on patient health care experiences. This pilot quality improvement project will provide OHE with important information about the feasibility, acceptability, and impact of new VA cultural competency training programs for PACTs designed to reduce unconscious bias and improve VA patient health care experiences.

Addiction Triage for Homeless: Enhancing VA Medical Homes (ANTHEM)

In FY13, with the support from the National Homeless PACT Program, Drs. Gordon and Broyles implemented ANTHEM to improve outcomes among homeless Veterans with substance use disorder (SUD). The ANTHEM PACT model is dually focused on: (1) providing dedicated case management for homeless Veterans within an existing PACT program; and (2) improving the care of alcohol and substance abuse for homeless and near homeless Veterans. The goals of the program are to eliminate barriers to quality health care and to improve health and housing outcomes for homeless Veterans and those at imminent risk of homelessness. Feedback from the National Homeless PACT Program office indicated that implementation of the ANTHEM program for a panel of 109 Veterans resulted in 40% reduction in emergency department (ED) use, a 63.5% reduction in hospital admissions, estimated cost savings from deferred ED visits and inpatient stays of $498,176, and estimated enhanced Veterans Equitable Resource Allocation (VERA) reimbursements of $784,800. This VAPHS program led by Drs. Gordon and Broyles, ranked first among the 36 Homeless PACTS throughout the country in reducing inappropriate hospitalizations.

Way to Health

This integrated research platform (waytohealth.org), developed by Drs. Asch and Volpp with support from the NIH, uses online tools, wireless technology, and other applications to support delivery and evaluation of behavioral interventions to improve health. The platform consists of 3 interconnected areas (i.e., study participant sites, research tools, and a secure database) that provide a sustainable information technology infrastructure for behavioral intervention studies. Investigators from CHERP, University of Pennsylvania, and other organizations (e.g., Weight Watchers, Blue Cross/Blue Shield, Harvard Vanguard Medical Associates) use the Way to Health to support randomized controlled trials of complex behavioral health interventions. Way to Health is currently being used by CHERP investigators to investigate behavioral economic approaches to improving cholesterol control (Asch and Volpp), diabetes control (Long), CPAP adherence (Kuna), medication adherence (Volpp and Asch), and weight loss (Volpp).

Publications

Brand-name prescription drug use among Veterans Affairs and Medicare Part D patients with diabetes: a national cohort comparison.
Gellad WF, Donohue JM, Zhao X, Mor MK, Thorpe CT, Smith J, Good CB, Fine MJ, Morden, NE.
Annals of Internal Medicine. 2013 Jul 16; 159(2):105-14

Diabetes patients on Medicare Part D are 2-3 times more likely to be prescribed brand-name drugs than comparable patients receiving care within the VA, at an added national cost of about $1 billion a year. Medicare and the VA have significantly different approaches to drug prescribing. Medicare contracts with >1,000 private insurance companies, each using a distinct formulary and cost-sharing arrangement for prescribing drugs. The VA uses a single formulary, and all Veterans have the same cost-sharing arrangement. Medication choice plays a large role in spending, with brand-name drugs costing substantially more than generics. Diabetes is a common, chronic condition with high medication use and a wide range of available therapies. Researchers analyzed health records for 1,061,095 Medicare Part D beneficiaries and 510,485 Veterans aged 65 years or older with diabetes to compare overall and regional rates of brand-name drug use. Of the 4 medication groups commonly used by patients with diabetes, Medicare beneficiaries were more than twice as likely as VA patients to use brand-name drugs in almost every region of the country. The researchers estimated that had patterns of medication use in Medicare patients mirrored those of the VA for these medications in patients with diabetes alone, the program could have saved more than $1 billion in 2008. Since strong evidence shows similar effectiveness of generic vs. brand-name drugs among the diabetes drug classes included in the study, switching to generics would improve efficiency without harming quality of care or access to effective medicines.

This paper was briefed to VA senior leaders, and Dr. Gellad was invited to present it to analysts at the Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency established by the Balanced Budget Act of 1997 to advise Congress on issues affecting the Medicare program.

Healthcare: The Journal of Delivery Science and Innovation
Dr. Werner served as Editor for the inaugural issue of Healthcare: The Journal of Delivery Science and Innovation, an new quarterly publication designed to promote and disseminate cutting edge research on innovation in healthcare delivery, including improvements in systems, processes, management, and applied information technology. The inaugural issue featured a commentary from Drs. Asch and Volpp ("Making the RCT More Useful for Innovation with Evidence-Based Evolutionary Testing") that proposes an innovative model to accelerate the development, testing, and evaluation of provider payment and health care delivery system initiatives.

HSR&D Director, Dr. David Atkins, commented on their work in his blog:

"I look forward to engaging the larger research community in an exchange and debate of the pros and cons of this and other innovative alternatives to the traditional 3-year RCT for practice and system-level interventions."

Dr. Werner is the journal Section Editor for Payment Reform, and Dr. Volpp is a member of the Editorial Board.