Cirrhosis, or advanced liver disease, is the 4th leading and fastest-growing cause of death in the US among those aged 45-64 and ranks among the top three leading causes of excess mortality in the US overall. Nearly 120,000 Veterans under the care of the Veterans Healthcare Administration (VHA) have cirrhosis due to alcohol, hepatitis C, fatty liver disease, or other causes, and this number is rapidly increasing. There are life- saving measures that providers can take to prevent harm from cirrhosis, including providing access to post- discharge follow-up care and screening for liver cancer and esophageal varices (veins that can cause catastrophic bleeding). However, less than 30% of Veterans receive care concordant with these three evidence-based practices (EBPs). Therefore, our operations partner, the HIV, Hepatitis, and Related Conditions Program Office (HHRC) created a learning collaborative to improve the uptake of cirrhosis EBPs in VA. As the evaluation team for this Hepatic Innovation Team (HIT) Collaborative, we have developed this Partnered Evaluation Initiative at the request of and in collaboration with HHRC. Through this PEI we aim to understand which implementation strategies, or discrete activities that are conducted to promote EBP implementation, can help improve the uptake of EBPs for cirrhosis care.
Our specific aims are to: 1) Empirically determine which combinations of implementation strategies are associated with the successful implementation of EBPs for Veterans with cirrhosis; 2) Use Intervention Mapping to operationalize these ?data-driven? implementation strategies; and 3) Assess the effectiveness of using data-driven implementation strategies to increase cirrhosis EBP uptake in a hybrid type III stepped wedge cluster randomized trial. To accomplish these aims we have adapted a survey of 73 implementation strategies, as defined by implementation science experts, that we successfully used in hepatitis C quality improvement efforts, with response rates of up to 84% nationally across 130 VA stations. We will administer this survey to all VA stations and use traditional statistical and configurational comparative methods to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. We will then use Intervention Mapping, a systematic, stakeholder-driven, six-step process for developing interventions and implementation strategies, to develop these strategies into a manualized, facilitated intervention, guided by the integrated-Promoting Action Research on Implementation in Health Services (i-PARIHS) framework. We will then test this implementation strategy bundle in 12 sites with low adherence to EBPs for Veterans with cirrhosis using a stepped wedge design in which four sites will cross from control to intervention approximately every 6 months. We will assess the impact of the implementation intervention on the primary outcome of patient level guideline-concordant care and on multiple measures of implementation (e.g., adoption, maintenance). Our work is at the request of our partner HHRC, and we have also partnered with investigators from the following centers and QUERIs: The National Hepatic Consortium for Redesigning Care (NCRC), BridgeQUERI, the QUERI for Team-Based Behavioral Health, Precision Monitoring to Transform Care (PRIS-M) QUERI, and the Office of Healthcare Transformation (OHT). This project is a natural extension of our prior work and aligns with HSR&D?s priorities regarding advancing implementation science and measurement methods, ORD?s priority to increase the real-world impact of VA work, and VA?s overarching goals to (1) focus resources more efficiently (by guiding sites towards effective and efficient practices) and (2) improve the quality and timeliness of services. Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform implementation interventions for low-performing sites, thus providing quality improvement tools that will allow VA to enhance the effectiveness and efficiency of national programming more broadly.

Public Health Relevance

Cirrhosis, or advanced liver disease, affects nearly 120,000 Veterans receiving care in the Veterans Health Administration (VA) and is a leading cause of death and disability. While there are strong evidence-based guidelines for providers managing patients with cirrhosis, only one-third of Veterans with cirrhosis receive care that is aligned with these guidelines. To improve the quality of care for Veterans with cirrhosis, VA?s HIV, Hepatitis and Related Conditions Program Office (HHRC) established the national Hepatic Innovation Team (HIT) Learning Collaborative, which includes more than 200 VA providers, staff, administrators, and leaders. As the HIT evaluation team, we worked with HHRC to develop this Partnered Evaluation Initiative (PEI) to improve the quality of care for Veterans with cirrhosis at VA sites across the country. The innovative methods that we develop through this PEI have the potential to increase the efficiency and effectiveness of cirrhosis care, improve Veteran health outcomes, and inform future VA quality improvement efforts.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I50)
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Veterans Health Administration
United States
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