Academic Detailing to Improve Opioid Safety: Implementation Lessons from a Qualitative Evaluation.

Objective: Academic detailing (AD) is a promising intervention to address the growing morbidity and mortality associated with opioids. While AD has been shown to be effective in improving provider prescribing practices across a range of conditions, it is unclear how best to implement AD. The present study was designed to identify key lessons for implementation based on a model AD program in the Veterans Health Administration (VA). Design: Qualitative process evaluation using semistructured interviews. Setting: Seven VA health care systems in the Sierra Pacific region. Subjects: Current and former academic detailers (N = 10) and VA providers with varying exposure to AD (high, low, or no; N = 20). Methods: Semistructured interviews were audio-recorded and transcribed. We used a team-based, mixed inductive and deductive approach guided by the Consolidated Framework for Implementation Research. Results: Key lessons identified by academic detailers and providers coalesced around key themes: 1) one-on-one sessions customized to the provider's patient population are most useful; 2) leadership plays a critical role in supporting providers' participation in AD programs; 3) tracking academic detailer and provider performance is important for improving performance for both groups; 4) academic detailers play a key role in motivating provider behavior change and thus training in Motivational Interviewing is highly valuable; and 5) academic detailers noted that networking is important for sharing implementation strategies and resources. Conclusions: Identifying and incorporating these key lessons into the implementation of complex interventions like AD are critical to facilitating uptake of evidence-based interventions addressing the opioid epidemic.

Leveraging electronic medical record data for population health management in the Veterans Health Administration: Successes and lessons learned.

PURPOSE: The process and operational elements to establish a population health program using electronic medical record data in a Veterans Health Administration region are described. SUMMARY: Pharmacists are uniquely qualified to assume important roles in population health through the use of their clinical knowledge, assisted by electronic tools that consolidate and report patient-specific data for clinical care. Veterans Integrated Services Network (VISN) 21 has developed 300 dashboards and reports to improve the quality, safety, and value of healthcare to veterans. Within a group of specialty task forces, physicians, nurses, and pharmacists assist in the design and development of evidence-based tools to leverage timely electronic health information into metrics, benchmarks, and targets to assist with goal achievement. Examples of programs designed to improve care in 3 areas were selected for further description and review of outcomes. Population health improvement using Healthcare Effectiveness Data and Information Set and hepatitis C metrics were used to describe populations that may have an indication for evidence-based care but are not receiving it. Deprescribing efforts are described, as are medication safety monitoring efforts to prevent potential adverse events known to be associated with therapy. CONCLUSION: Quality, safety, and value outcomes are the measures of success for population health programs in VISN 21. Data-rich project dashboards and reports are developed by pharmacist data analysts and implemented and used by teams of clinicians who provide continuous feedback and support to improve population health. The use of task forces, metrics, benchmarks, targets, and teams is instrumental in the successful application of these tools.

Determinants of Treatment Eligibility in Veterans With Hepatitis C Viral Infection.

PURPOSES: The objective of this study was to determine the percentage of veterans with active hepatitis C virus (HCV) infection who were deemed to be candidates for treatment and to identify factors associated with treatment ineligibility. METHODS: This was a multisite, retrospective cohort analysis of veterans with HCV infection within the Veteran Integrated Service Network 21. Patients evaluated between August and November 2015 who were viremic and not receiving HCV treatment were included in the analysis. Reasons for treatment exclusion were determined by an experienced clinician and recorded into a regional population management dashboard. Descriptive statistics were used to describe the population. The t test for normally distributed data, the Mann-Whitney rank sum test for data that failed normality testing, or the χ2 test were used to examine differences between the treatment eligible and ineligible cohorts. Generalized linear mixed-effects models were conducted to estimate patient outcomes relevant to various disease states and characteristics while controlling for interfacility variability. FINDINGS: The cohort included 1,003 veterans within 5 medical centers; 988 (98.5%) were male, and 625 (62%) had a fibrosis 4 score >3.25, indicating the presence of ALD. According to clinician classification, 478 (48%) were considered HCV treatment candidates, whereas 525 (52%) were determined to be treatment ineligible. The most common reasons documented by clinicians for treatment ineligibility included unstable or uncontrolled comorbidities (n = 118 [22.4%]), excessive alcohol use (n = 116 [22.1%]), and treatment refusal by the patient (n = 69 [13%]). On the basis of statistical modeling and reporting odds ratios (ORs) and 95% CIs, diagnoses of active alcohol use disorder (OR = 0.68; 95% CI, 0.47-0.98; P = 0.038), hepatocellular carcinoma (OR = 0.24; 95% CI, 0.13-0.47; P < 0.001), and palliative care status (OR = 0.21; 95% CI, 0.05-0.99; P = 0.049) were statistically associated with treatment ineligibility, whereas posttraumatic stress disorder (OR = 1.48; 95% CI, 1.01-2.18; P = 0.046) was associated with treatment eligibility. There were no statistically significant differences found for other psychiatric diagnoses or an encounter for homelessness. IMPLICATIONS: Results of this study indicate that a high percentage of patients may not be considered treatment eligible at initial clinical review. Within this veteran population, the presence of uncontrolled comorbidities and excessive alcohol use were the most commonly reported reasons for treatment ineligibility. On the basis of this analysis, processes could be established to address modifiable barriers to treatment, thus expanding the number of individuals receiving potentially curative therapy for HCV infection.

Establishment and outcomes of a model primary care pharmacy service system.

PURPOSE: The establishment and outcomes of a model primary care pharmacy service system are described. SUMMARY: A primary care pharmacy practice model was established at a government health care facility in March 1996. The original objective was to establish a primary pharmacy practice model that would demonstrate improved patient outcomes and maximize the pharmacist's contributions to drug therapy. Since its inception, many improvements have been realized and supported by advanced computer and automated systems, expanded disease state management practices, and unique practitioner and administrative support. Many outcomes studies have been performed on the pharmacist-initiated and -managed clinics, leading to improved patient care and conveying the quality-conscious and cost-effective role pharmacists can play as independent practitioners in this environment. These activities demonstrate cutting-edge leadership in health-system pharmacy. Redesign has been used to improve consistent access to a medication expert and has significantly improved the quality of patient care while easing physicians' workload without increasing health care costs. CONCLUSION: A system using pharmacists as independent practitioners to promote primary care has achieved high-quality and cost-effective patient care.