Welcome to Collective Conversations, a series of discussions aimed at highlighting people and groups working to improve health through better health care systems.
In this conversation, you'll hear from the Chief Scientific Officer for the VA’s Primary Care Innovation Lab (PCIL), Dr. Ashok Reddy. I'm confident that you'll appreciate the strategies he shares based off of his experience from PCIL.
Joy Lee: Can you tell us about the origin of PCIL?
Ashok Reddy: The Primary Care Innovation Lab, or PCIL, really comes out of our Primary Care Analytics Team, which is an embedded unit within the Office of Primary Care in the VA that really serves a mission with the Office of Primary Care to do program evaluation, program planning, innovation development, and evidence synthesis. We really think about the Primary Care Analytics Team in general as this embedded unit for the Office of Primary Care to really support a learning health system, which tries to integrate internal data and clinical expertise with external evidence, and try to put those resulting evidence into practice. And so, the Primary Care Innovation Lab really comes out of that mission and vision. And what we’ve noticed over the past decade is that as the primary care clinic has really evolved, there has been a lot of quality improvement efforts to improve the delivery of primary care to veterans. Unfortunately, the problem we see is that we don’t always know if these quality improvement efforts are working. Often, we don’t evaluate them in rigorous ways. And it’s often left us with more questions than answers. And so, the Primary Care Analytics Team really created the Primary Care Innovation Lab to address this problem and really work with local operations teams through rigorous project development.
JL: I really love this response in creating the lab to the problems that you guys solve and the idea that we really need to evaluate it so our quality improvement projects are actually supporting our patients the way that they think we should.
AR: Yeah, I do think that often we want to improve care in some way, but often we don’t know how we can learn from that and if it actually is improving care. So, we really tried to develop this lab to rapidly design, test, and evaluate these quality improvement initiatives to really understand and improve the delivery of primary care.
JL: Could you walk us through how projects are prioritized to PCIL?
AR: I think to really understand how the projects are prioritized, I think understanding a little bit about who’s on the team can be helpful. This is really a partnership with the operations team locally in primary care. And on that local operations efforts, those are really getting the input of the primary care leadership at our organization – the nursing staffs, administrative managers, directors of their own analytics/informatics teams – so, we really try to incorporate those operations committee into the design and basically being able to pick the projects. And so, we use our core team in terms of our Primary Care Innovation Lab team to really help design that. I serve as the Chief Data Scientist. We have a director, Dr. Stefanie Deeds, who bridges our team and the operations committees. We have a number of other researchers, clinicians, and analysts that help support these projects that get picked.
Getting back to your question about how do these projects get picked – I think it really comes from the primary care staff. So, we annually have done an email blast to all primary care staff to think about ideas of how to improve the delivery of primary care. This last year, we got 26 different ideas and we were able to kind of take those ideas and have those reviewed by our operations committees and core team members to think about how relevant they are? Could they be actually done? Is there an actual intervention that could be done? And so, we basically took all those ideas, reviewed those with the committee and the core team to identify projects that could be designed, tested, and evaluated.
JL: It just sounds like a really great turnout from the staffs that you had so many ideas come to you in the first run.
AR: I think it’s a real testament to how engaged our nurses, administrators, physicians are in trying to improve the delivery of primary care here, locally. And I think it’s also a testament to that we have been able to show the value of doing these types of projects that I think really helps garner that support.
JL: One of your projects aimed to understand if phone and/or text reminders enhanced return of mailed FIT tests – a screening test for colon cancer. Would you tell us more about this project and its findings?
AR: One of the things we noticed with the pandemic was that a lot of our typical cancer screenings that were traditionally done with a face-to-face visit and ordered then and there weren’t being done because a lot of care had transitioned to telephone or video. And one in particular was colorectal screening. We know through other population health interventions to improve colorectal screening that mailing certain kits to measure for colorectal cancer screening can improve uptake of this screening modality to really try to get patients earlier to find cancer earlier and to improve their mortality. And so, the clinic really wanted to adopt a male FIT program. So, FIT stands for Fecal Immunochemical Testing – it’s a validated in-home method for colorectal cancer screening. And this was an important priority for our local primary care team to try to identify patients that needed colorectal cancer screening and to deliver this kit through the mail. And so, there has been a number of studies that have recommended that clinics or health systems adopt male FIT approach to try to get patients the colorectal cancer screening they need. But we often don’t know what are the strategies to improve their uptake because often these programs only have about 30% uptake, meaning that the patients who get the FIT only return them 30% of the time. And we wanted to try to identify ways to try to improve that.
One of the ways we did was to send out a reminder to patients, whether via phone or text message to have them return their FIT card about 2 weeks after they got their FIT card. So, we were able to randomize nearly 2,500 veterans to get a male FIT. And then we were able to randomize them to either not getting the reminder, those that got a text reminder, or those that got an automated call. And what was really of interest to the operations team was 1) do reminders improve the uptake of colorectal screening? and 2) does it matter whether you send out a text message or a phone call to remind veterans to return their FIT card?
And what we have found is that, as I’ve mentioned before, the control group had about a 30% return rate for these FIT cards. But whether or not it was an automated call or a text message, that had a 10% increase in colorectal cancer screening. So, close to 40% of patients returned their FIT card after getting the reminder.
JL: How long did this go for?
AR: We were able to design all of this within a short period of time. The project was within about 6 months to a year that this has been able to take place. Once we were able to gather the information about which patients needed to get colorectal cancer screening, we were able to send out the reminders and phone calls within 2 weeks after they received colorectal screening.
JL: Given that PCIL carries out different pilot care delivery projects, how do you disseminate those findings to key stakeholders? And who are those key stakeholders?
AR: I think this fits into the trust and relationships that we’ve built with the primary care team and the operations team here locally. So, these are our key stakeholders, which is really the primary care team – the nurses, administrators, physicians. So, we’ve been able to not only present these results to our regular operations teams and give them updates on how the project is going along the way, and once we get the results, we were able to disseminate that through our regular meetings with the operations team. So, that’s been our primary way of delivering and sharing that communication. This involves often presentations that we lead and develop. Sometimes, we’re able to come up with one-page summaries that we disseminate both locally and to the Office of Primary Care nationally. So, those are our immediate ways to disseminate our findings to key stakeholders.
JL: Can you share 2-3 strategies in working with clinical operations partners that you think others in primary care settings would benefit from, especially if they’re thinking of carrying out quality improvement projects like those run in PCIL?
AR: I think part of this is really understanding what are the mission and challenges that operations partners really have. And I think often researchers don’t do a good job of understanding that. And typically the timelines are very different than research. Often, in research, we think about designing projects that may take years, where operations partners are trying to change delivery now to improve the care and have to make the decisions now. So, really understanding what those challenges are there, and I think the level of evidence required to help operations leaders make decisions is also very different. So, really understanding that is important. And then lastly, it is really important in terms of developing a trusting relationship with an operational partner that really takes time. So, when I think about strategies for collaboration, I think it really starts with relationships and developing those trusted partnerships that are really important. And to really do that well, I think you have to have open communication, really share results early and often throughout the project to really help them understand what are the challenges or barriers that are happening, and can we get over those quickly? So, in terms of strategies, I think thinking about how to communicate is really an important one and developing that strategy early.
I think the other thing that we’ve done here at the Primary Care Analytics Team and with the Primary Care Innovation Lab has really developed stories that go along with these studies to really develop qualitative narratives that go along with [the studies], because I think those are really important in helping operations leaders make decisions. And so, we often try to couple our projects with some early qualitative work around what’s happening on the ground, what are the challenges, things of that nature.
JL: Thank you so much for sharing these very attainable and practical strategies, and also the learnings from the Primary Care Innovation Lab. I appreciate your time.
AR: Thank you.