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25 Years of QUERI Highlights and Impacts

Since its inception in 1998, QUERI’s mission has been centered on improving Veterans’ health and well-being by accelerating evidence into healthcare practice and policy. Over the last 25 years, QUERI has grown to become a national network of more than 200 investigators and staff committed to leveraging their health services and implementation science expertise to ensure Veterans and their families receive the best possible care and support.

I have really enjoyed doing quality improvement work with frontline providers, as well as doing a thoughtful but practical evaluation of these quality improvement efforts. I’m particularly happy that the work we have done has directly improved clinical practice… —QUERI Investigator/Staff

Early Impacts on Veteran Care and Outcomes

The first QUERI centers focused on enhancing healthcare and Veterans’ health outcomes for high-priority conditions prevalent among Veterans, including: Chronic Heart Failure, Colorectal Cancer, Diabetes Mellitus, HIV/AIDs, Ischemic Heart Disease, Mental Health, Polytrauma, Spinal Cord Injury, Stroke, and Substance Use Disorder.

Here are just a few of their accomplishments:

Chronic Heart Failure (CHF) QUERI made significant contributions in the areas of safety, hospital readmissions, use of life-prolonging therapy, as well as the de-implementation of unnecessary cardiac imaging. For example, their Reducing Unnecessary Hospitalizations for Veterans with CHF: The Hospital-to-Home (H2H) campaign resulted in a reduction in hospital days for 80 participating VA facilities. Across the VA healthcare system, H2H participation was associated with a reduction of 21,000 hospital days each year, which translated to cost savings of approximately $18 million per year.

HIV/Hepatitis (HH) QUERI made tremendous progress in several key areas, including: better disease identification; improving linkage, retention, and adherence to care; and reorganizing care for improved coordination and value. For example, HH-QUERI investigators developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. 

Ischemic Heart Disease (IHD) QUERI made significant contributions to improving the health and care of Veterans with IHD. For example, working with VA Patient Care Services (PCS), the Office of Quality and Performance, and the Office of Information and Technology (OI&T), IHD QUERI developed the Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL).

Spinal Cord Injury (SCI/D) QUERI developed a successful implementation program that was rolled out to VA SCI Centers and increased rates of both influenza and pneumococcal immunization. This resulted in influenza vaccination rates increasing from 28% in 2000 to 79% in 2010, and pneumococcal pneumonia vaccination rates increasing from 40% in 2000 and to 94% in 2010 among Veterans with SCI/D.

Recent Impacts on Veterans, VA Employees, and the VA Healthcare System

QUERI continues to partner with VA providers and staff, leaders, and Veterans to reduce unwarranted clinical and service variation across the VA healthcare system. To ensure QUERI initiatives are leading to sustained improvements in healthcare and Veterans’ health outcomes and to promote greater alignment between QUERI teams and their clinical and operations partners, QUERI measures the overall health, economic, policy, and cultural impacts of QUERI activities on the VA health system, VA employees, and Veterans (Braganza and Kilbourne, 2020).

  Summary of QUERI ACTION Impact Framework, Braganza, et al, JGIM, 2020

Currently, QUERI’s 14 Programs and 3 multi-VISN Partnered Implementation Initiatives are scaling-up, spreading, and sustaining more than 40 effective practices that address national and regional goals.

Our office works with QUERI on several projects, and their engagement has led to the development and improvement of [our] programming across VHA, resulting in tangible positive outcomes for Veterans, their families, and caregivers. —National VA Program Office Leader

Since 2020, QUERI has supported more than 50 national and regional partnered evaluations to help optimize the rollout of programs and policies affecting Veterans and over 30 Rapid Response Team projects to address emerging issues, including COVID-19.

My program has worked with QUERI investigators to evaluate new initiatives. The work done has helped us understand the needs of our network, and now we can begin to expand those initiatives into the right local market. —VA Facility/VISN Leader

QUERI quality improvement efforts touch all 18 VISNs and have helped inform care improvements for more than 5.3 million Veterans.   

Specific QUERI initiatives and impacts were highlighted in the 2020 GAO report, VA Health Care: Efforts to Prioritize and Translate Research into Clinical Practice; more recent impacts include:

• Behavioral Health Interdisciplinary Program - Collaborative Care Model helped decrease hospitalization rates (70 fewer hospital days per site), improve mental health status for Veterans with three or more mental health conditions, and yield cost savings of $1.70 for every dollar spent. (Miller et al., 2020)
• Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT), an evidence-based practice to improve care for Veterans with transient ischemic attack, was deployed across 85 sites.
• STRIDE, a walking program for hospitalized older adults, was selected as a Diffusion of Excellence gold status practice for national implementation and has trained 879 providers and served more than 7,700 Veterans, to date.
• Caregivers FIRST has impacted more than 2,100 caregivers of Veterans, providing basic skills, self-care, and peer support.
• Advanced Care Planning via Group Visits has been implemented at 75 VA sites, serving 50,865 Veterans, to date.
• Stepped Care for Opioid Use Disorder Treatment (SCOUTT) increased the number of Veterans with opioid use disorder receiving buprenorphine in SCOUTT clinics by 267%.

Further, QUERI is striving to make VA a thought leader in linking implementation science and evidence-based policy. In partnership with various program offices, QUERI teams have provided analytical and evaluation support to help address legislative priorities, including the MISSION Act, Hannon Act, and PACT Act. Key examples include:

• Improving Access to Legal Services for Veterans (LSV) Partnered Evaluation Initiative is helping to inform the Homeless Programs Office’s implementation of LSV, a Congressionally mandated initiative to fund legal services for Veterans by awarding grants to legal service-providing organizations in the community.
• Function QUERI and EMPOWER QUERI are providing evaluation support to help inform VA’s Office of Women’s Health’s implementation of a national program for childcare assistance for certain Veterans seeking healthcare, in response to the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 (Section 5107).
• Behavioral Health QUERI created two evaluation plans that are being used by the Office of Mental Health and Suicide Prevention to comply with Section 201 of the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019.
• PEPReC is supporting implementation of the MISSION Act in VA by: 1) Creating an underserved model for primary care that was used by the Offices of Veterans Access to Care, Rural Health, and Primary Care to target resources to underserved facilities; 2) Assisting with the design of an evaluation to assess the impact of VA hired vs contract-hired scribes; and 3) Providing technical assistance to the Center for Care and Payment Innovation (CCPI) on the design of pilots.

In addition to addressing specific legislative priorities, QUERI is helping implement Learning Health System goals on a broader level, leveraging resources across VHA to address healthcare challenges that cut across multiple program offices, service lines, and VISNs. Since 2019, QUERI has worked with the Chief Strategy and Finance Offices to manage VHA’s response to the Foundations for Evidence-Based Policymaking Act of 2018 (Evidence Act). The success of these efforts has led to the:

• Creation of the first-ever Evidence-based Policy Subcommittee under VHA’s governance;
• Inclusion of QUERI’s national systematic process(to identify priorities for Evidence Act evaluations) in the VA FY2022-2028 Strategic Plan;
• Online publication of VHA Evidence Act deliverables, including the VA FY2023 Annual Evaluation Plan;
• Assessment of the level of evidence for over 300 legislative, budget, and regulatory proposals using the PEPReC-developed Strength of Evidence Checklist.

Due to the increasing demand for implementation science expertise, QUERI created new training and mentoring opportunities, including:

• Advancing Diversity in Implementation Leadership (ADIL) initiative: 15 ADIL awardees, to date;
• Mentoring Cores: 80+ early career investigators and staff receive mentoring;
• Nine Implementation Strategy and QI Learning Hubs provide a unique opportunity for leaders, providers, and researchers across VA to gain the practical experience and skills needed to lead care improvements at their site.

Looking forward, QUERI will continue to support national implementation evaluations on cross-cutting topics, promoting team science and multi-level partnerships; create resources to increase the use of implementation science methods across the translation spectrum; empower its workforce in a changing world; and foster a national network of knowledge translation and learning.