Center for Clinical Health Policy Research
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Implementation

 
ImplementationCCHPR addreses the entire spectrum of clinical health policy from its development using evidence-based approaches to strategies for optimal implementation.  Our goal is to bridge theory and practice in a way that both advances the state of the scientific theory and is sufficiently proagmatic to actually improve health care practice.  Implementation of clinical health policy invloves:  (a) analyzing current practices, (b) comparing current practices with optimal practice, (c) designing strategies for practice improvement, and (d) evaluating the effects of these intervention strategies.
Consistent with this objective, we have successfully undertaken several projects that address the above steps in implementation of clinical health policy.
 
 
 

Ten-Site Implementation of the Advanced Chronic Kidney Disease Practice Improvement Toolkit 

Dates: 4/1/2008-10/1/2009
 
PI: David Matchar, MD, FACP, FAHA
 
Project Type: Implementation
 
Funders/Sponsors: Renal Physicians Association (RPA)
 
The RPA-10 Site Project is a joint effort between the Renal Physicians Association (RPA) and the Duke Center for Clinical Health Policy Research (CCHPR).  Prior RPA-Duke collaboration resulted in the development and pilot-testing of the Advanced CKD Patient Management Toolkit.  The purpose of this current, RPA-10 Site Project, is to help participating nephrology practices implement and customize the Toolkit to help them manage CKD more easily and effectively, and to evaluate that effort.
 
Specific aims include:
 
1) Evaluate the utility of the Advanced CKD Patient Management Toolkit in implementing the advanced CKD guideline in various nephrology practice settings, including those with and without EMR;
2) Assess care patterns, practices, and variation, adequacy of advanced CKD management, targets of intervention, and changes in processes required to improve care;
3) Evaluate the impact of the implementation exercise on improved conformance to guideline recommendations using a case-control design.
 

Pharmacogenetics, Biomarkers, and Antithrombotic Therapy 

Dates: 9/2003-8/2007
 
PI: David Matchar, MD, FACP, FAHA 
 
Project Type: Implementation
 Improve the safety and the effectiveness of anticoagulant therapy. The ancillary study, Pharmacogenetics, Biomarkers, and Antithrombotic Therapy, is ancillary to the main THINRS study. This ancillary study will elucidate pharmacogenetic and nongenetic markers that influence the response to warfarin. Besides contributing scientifically, Dr. David Matchar will interpret the ancillary study findings in the broad context of Internal Medicine and Health Policy and will participate in writing and editing manuscripts related to the study.
 

A Randomized Trial of Headache Management Programs 

Dates: 9/2001-9/2005
 
PI: David Matchar, MD, FACP, FAHA
 
Project Type: Implementation
 
 To determine whether Headache Management Programs (HMPs) should be promoted as an effective and cost-effective strategy for managing patients with chronic disabling headache. The specific aims are: 1) Demonstrate through a randomized, controlled trial enrolling patients with chronic headache that those receiving the intervention (HMP) will have better outcomes, including decreased disability related to headache (primary outcome), improved quality of life and improved satisfaction with care (secondary outcomes); 2) Demonstrate through a randomized, controlled trial enrolling patients with chronic headache that those in the intervention group will have better processes of care; among others, they will have a higher appropriate diagnostic testing and a higher rate of appropriate acute and preventive therapy; 3) Demonstrate through a randomized, controlled trial and comparison of cost data across sites that the headache management program will provide a cost-effective method for managing chronic headache patients.
 

Improving the Quality of Diabetes Eye Care 

Dates: 9/2003-8/2007
 
PI: Paul Lee, MD, JD
 
Project Type: Implementation
 The study is a randomized controlled trial that seeks to compare to a control group the efficacy of two levels of structured interventions that directly address both competency and technical process quality.
 

American Headache Society (AHS) - Primary Care Migraine Partnership (PCMP) Outcomes Measurement and Assessment 

Dates: 3/2003-5/2004
 
PI: David Matchar, MD, FACP, FAHA
 
Project Type: Implementation
 Evaluate the impact of a headache educational program, "Brainstorm", on what physicians believe, know, and do. We aimed at tracking the success of the program by measuring outcomes, and monitoring improvement in physician behavior and patient care. We conducted a prospective case-control research design (100 physicians in each arm) to compare performance of attendee and non-attendee physicians and provide a follow-up evaluation immediately after the CME, and at three and nine month intervals for physicians who have attended the continuing medical education (CME) program.

To assess changes in behavior and attitudes of physicians, we conducted an innovative approach utilizing standardized patients (SPs), along with the conventional tools i.e. questionnaires and vignettes. We will also compared physician performance with SPs and performance on written tests and vignettes. In addition we monitored prescribing patterns of participants through surveys, and patient satisfaction through SP assessment of the medical encounter.
 

Hypertension Improvement Project

Dates: 2/2004-1/2009
 
PI: Rowena Dolor, MD
 
Project Type: Implementation
 This is a randomized, controlled trial that will test the separate and combined effects on BP control of a continuous quality improvement (CQI) intervention for physicians and a behavioral intervention for patients.
 

Longitudinal Evaluation of Cancer-Related Symptoms and Quality of Life: A Pilot Study of an E-tablet Based Data Collection System for Patients with Breast and Colorectal Cancer

PI: Amy Abernethy, MD
 
Project Type: Implementation
 This study will assess the feasibility of e-tablets as a mechanism for collecting patient-reported information. In the course of this study, we also hope to learn whether e-tablets can be used to collect survey data from common instruments used in clinical practice and trials here at Duke, such as the Functional Assessment of Chronic Illness Therapy (FACT) QOL scale, and to better understand the practical challenges and solutions to using this technology in our environment. The study will serve as a local validation study of the Patient Care Monitor survey instrument, the data collection tool most commonly used with e-tablets, as compared to standard survey instruments such as the FACT.
 

Longitudinal Evaluation of Management Strategies and Their Impact in Metastatic Colon Cancer: A Retrospective Chart Review

Dates: 7/2006-6/2007
 
PI: Amy Abernethy, MD
 
Project Type: Implementation
 The study will describe: (1) the pattern of use of different chemotherapeutic regimens for the management of metastatic colorectal cancer (CRC) across community oncology sites associated with the Duke Oncology Network (DON); and (2) the reasons that community oncologists' prescribing changes from first-line to second-line to subsequent-line treatments in the management of metastatic CRC. We will focus specifically on FOLFOX and FOLFIRI with or without bevacizumab as first-line regimens. Secondary objectives include to describe (a) the community oncology experience with different first-line regimens in metastatic CRC in terms of toxicity and disease progression, with different second-line and higher order regimens in metastatic; (c) prior adjuvant chemotherapy regimens chosen for the patients included in this chart review; and (d) any documented patient preferences between various treatment regimens. We will determine if there is a difference in rates of second-line chemotherapy for metastatic CRC when FOLFOX vs. FOLFIRI is the first-line choice. We will also describe, within this community sample of patients that ultimately develop metastatic disease, oncologists' performance for management of non-metastatic CRC relative to known evidence-based quality metrics. This inquiry will prepare us to develop a set of proposed quality metrics for the management of metastatic CRC.
 

Pilot Testing of the Advanced Chronic Kidney Disease Practice Improvement Toolkit

Dates: 7/2004-8/2005
 
PI: Meenal B. Patwardhan, MD, MHSA
 
Project Type: Implementation
 The goal of the study is to understand (a) existing practice patterns for patients with advanced CKD across the US by specialty, (b) the socio-economic and health care environment in which ACKD patients are managed, and (c) to implement a set of advanced chronic kidney disease guidelines using specific, clinically attractive tools in a real-world practice. For this purpose we will overlay an application of the tools with a detailed observation of the process by which this practice improvement effort takes place. The insights gained by this close observation should be applicable to revising the tools if necessary, providing recommendations for how barriers to practice improvement might be overcome, and so forth. Another aspect of the project is to assess the social and economic environment of the practices, and the specific problems that practices face in the area of the management of chronic kidney disease. This will help us better understand the challenges of various practice situations - in terms of their geography, their patient demographics and availability (or non-availability) of nephrologists.
 

Stroke QUERI 

Dates: 4/2004-3/2007
 
PI: David Matchar, MD, FACP, FAHA
 
Project Type: Implementation
 There are four stated primary goals of the stroke QUERI. The first goal is to improve overall compliance with the Department of Veterans Affairs (VA) and the Department of Defense (DoD) clinical practice guideline for the management of stroke rehabilitation in the primary care setting. The second goal is to ensure that a plan for rehabilitation is considered for all stroke patients. The third goal is to reduce the risk of stroke recurrence by assuring appropriate anticoagulation of stroke patients with atrial fibrillation. The fourth goal is to reduce the physical, emotional, and social burden of post-stroke depression. David's role is to coordinate goal 3 including: 1) evaluation of VA computer database to determine the rate, quality and outcome of anticoagulating stroke patients with atrial fibrillation; 2) survey VISN 6 facilities regarding general strategies and innovation approach to anticoagulation.
 

WHO BP Device

PI: David Matchar, MD, FACP, FAHA
 
Project Type: Implementation
 The general aim of this project to evaluate a blood pressure measurement device satisfying World Health Organization specifications. The specific aims are to determine in representative sites in developing countries:
(a) the technical appropriateness of the specifications,
(b) the feasibility of implementing a program for blood pressure screening and management using such a device in developing countries, and
(c) the factors that would inform a business case for such a device.

As a pilot study, a secondary aim is to evaluate the efficacy of device to identify and control blood pressure in a target population.
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