The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods

Abstract

Background: Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles.

Methods: This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability.

Discussion: PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines.

Trial registration: clinicaltrials.gov: NCT02769338 [May 11, 2016].

Keywords: Audit and feedback; Cerebrovascular disease; Implementation science; Learning healthcare system; Quality of care; Systems redesign; Transient ischemic attack.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Intervention Components Mapped onto Barriers to Providing Quality Care. Figure 1 displays the barriers to providing excellent quality of care for patients with transient ischemic attack (TIA) or minor stroke that were identified through interviews with front-line clinicians as well as the components of the PREVENT program that were designed to overcome each barrier

Fig. 2

The PREVENT Web-Based Hub. The home page of the web-based PREVENT Hub included a prominent display of the facility without-fail rate (upper left red box) and the pass rates for each of the seven key processes of care (in blue text)

Fig. 3

PREVENT Stepped-wedge Design. The stepped-wedge design included two sites per wave and a total of three waves. The study included: a 12-month baseline period (yellow); a12-month post-implementation period (orange), which began with a kick-off (brown), and during which the site teams participated in monthly virtual collaborative sessions (telephone symbol); and a sustainability period (blue)

Fig. 4

PREVENT Sample Size Design. The panels display how the power curves vary with changes in the coefficient of variation (CV)