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Improving Care for Veterans with Minor Stroke: The PREVENT Program

More than 8,500 Veterans with transient ischemic attack (TIA) or minor stroke are cared for in VA emergency departments (ED) or inpatient wards each year. Patients with TIA and minor stroke are at very high risk of recurrent vascular events and yet are relatively free of symptoms; therefore, they are ideal candidates for risk factor management. Data from non-VA settings has demonstrated that 70% of recurrent vascular events can be avoided by programs that enhance timely medical care.

Unfortunately, benchmarking VA data demonstrated that although quality of care for ischemic stroke has improved across the VA healthcare system, gaps in care exist for Veterans with TIA and minor stroke. A previous QUERI-funded study showed that only 25% of Veterans with TIA receive without-fail care, meaning that only 1 in 4 Veterans with TIA received all of the care for which they were eligible from among seven guideline-concordant processes of care, including: brain imaging, carotid imaging, anti-thrombotics, anticoagulation for atrial fibrillation, hypertension control, high/moderate potency statin, and neurology consultation. 

To address this clinical priority, QUERI’s Precision Monitoring to Transform Care (PRIS-M) program’s Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) project is being implemented at six sites across VA to ensure that Veterans with TIA and minor stroke receive the care they need to reduce their risk of recurrent vascular events. PREVENT includes a multi-dimensional intervention that was designed on the basis of interviews with frontline VA providers, which identified key processes of care that should serve as targets for quality improvement, and effective non-VA TIA programs. The PREVENT intervention components include: professional education, data feedback, quality improvement support, clinical programs, and EHR tools (see table below).

PREVENT’s one-year active implementation period began on the day of the Kick-Off, in which a nurse-facilitator guided the local multidisciplinary team. During the Kick-Off, site team members:

• Reviewed the evidence supporting the importance and urgency of TIA care,
• Examined their facility’s quality of care data to identify processes that might serve as the focus for quality improvement activities,
• Identified barriers contributing to gaps in care quality,
• Generated solutions and goals, and
• Formulated an implementation plan.

These plans and goals are updated monthly during the PREVENT Virtual Collaborative Calls, which also are led by the nurse facilitator. During these calls, participants from the various sites share both successes and frustrations, and build a virtual community of practice. Participation in the monthly calls is exceeding expectations.

In addition, the PREVENT program employs three primary implementation strategies:

• Team activation via audit and feedback, reflecting and evaluating, planning, and goal setting;
• External facilitation; and
• Building a community of practice.

PREVENT also allows for local adaptation of the intervention and also leverage peer networks to support implementation

PREVENT is expected to contribute to our understanding of how ongoing performance data based on validated electronic quality metrics—not chart review—may motivate quality improvement in settings and improve veteran care where there are no national performance standards or directives. PREVENT also will demonstrate implementation strategies that can support teams in the ongoing use of data for quality improvement.