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Evidence Based Practice in VHA

Presentation to the Advisory Committee on Gulf War Veterans

Joseph Francis, MD, MPH

Deputy Chief Quality & Performance Officer

September 24, 2008

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VA/DoD EBP Working Group Charter

Vision “advise … on the use of practice guidelines to improve

the quality of health and support population health management”

Purposes advise the VA/DoD Executive Council identify areas for guideline adaptation facilitate adaptation process identify maintenance process champion the integration into information systems ensure integration encourage research

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VA/DoD Evidence-Based Practice Workgroup Structure

Evidence-Based Knowledge Management &Transfer

Co-Chaired by VA & DoD

Evaluation & AnalysisCo-Chaired by VA & DoD

Clinical Portfolio Management & Development

Co-Chaired by VA & DoD

Health Executive CouncilCo-Chaired by VA & DoD

Joint Executive CouncilCo-Chaired by VA & DoD

VA/DoD Evidence-Based Practice Workgroup

Co-Chaired by VA & DoD

Decision Support Co-Chaired by VA & DoD

Review Co-Chaired by VA & DoD

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VA/DoD EBP Workgroup MembersVA Members Joseph Francis, MD- Co-Chair Linda Kinsinger, MD – Director

National Center for Prevention Len Pogach MD – Chief

Consultant, Diabetes Rick Owens, MD - Medical

Advisory Panel Carla Cassidy, RN - Director,

Evidence-Based Practice Guidelines

Patricia Rikli, RN - Employee Education System

David Atkins MD – Quality Enhancement Research Initiative

Peter Almenoff, MD - VISN 15 Doug Owens MD: HSR&D Seyed Tirmizi, MD - Informatics

DoD Members COL Doreen Lounsbery, MD - Co-

Chair Army Medical Department Lt Col Patrick Monahan, MD - Air

Force CDR Annette Von Thun, MD - Navy Col Joyce Grissom, MD -Tricare COL John Kugler, MD - Tricare LTC Nhan Do, MD - Medical

Informatics Mark Hamra MD – Medical Informatics COL Ernest Degenhardt, AN – Chief,

Evidence-Based Practice Lt Col James McCrary, RPh

Pharmacoeconomics Center CAPT Kevin Lee Gallagher, M.D.,

Region Representative

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Features of the VA-DoD EBPWG

Allows tailoring to the needs of the current or former warriormay assist seamless transition

Free of Conflicts of Interest Strong adoption of evidentiary

standards Focus on algorithms and other tools to

assist providers Able to drive clinical policy

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Current Clinical Practice Guidelines

Post Deployment Health Assessment Uncomplicated Pregnancy Major Depressive Disorder PTSD Psychosis Substance abuse disorder Medically Unexplained Symptoms Opioid Use in Chronic Pain Mild TBI Post Operative Pain Bio/Chem/Rad/Blast Injury Tobacco Use Cessation Obesity Amputation Disease Prevention

Heart Failure Hypertension Ischemic Heart Disease Dyslipidemia Diabetes Mellitus Pre End Stage Renal Disease COPD Stroke Rehabilitation Acute Stroke Rehabilitation Dysuria Asthma GERD Glaucoma Erectile Dysfunction Low Back Pain

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Evidence as the Basisfor Clinical Policy

ClinicalGuidelines

Evidence

FormularyClinical

Processes & Systems

AppropriatenessMeasures

DecisionSupport

PerformanceMeasures

ClinicalReminders

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Rating the Quality of Evidence (USPTF, 1996)

Grade I: RCT Grade II-1: nonrandomized trial Grade II-2: cohort or case-control Grade II-3: multiple time-series Grade III: opinions of experts

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Rating System used for MUS Guideline (USPSTF, 1996)

Grade A: Strong recommendation Grade B: Recommended Grade C: Recommendation not well

established (may have value in some) Grade D: Considered not useful/effective Grade E: Strong evidence NOT to use

(ineffective or harmful)

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Issues with Guidelines

Patients with multiple problems and conditionsmost clinical trials excluderecommendations for one condition may

contradict those for another Conflicts of interest

are they “evidence” or “industry” based? Special populations (e.g. elderly) not

specifically studied in clinical trials

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You don’t need a guideline to cover the basics:

Professionalism Compassion Communication Continuity and coordination Responsiveness Truth telling Shared decision-making with patients and family Teamwork

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Goals of MUS Guideline

Promote effective assessment of patient's complaints.

Optimally manage symptoms Avoid harm (complications and morbidity)

including the harm caused by treatment Achieve satisfaction and positive

attitudes regarding the management of chronic unexplained illness

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MUS – Sample recommendations

Grade A: Strongly recommendedValidate the patient’s thoughts, feelings,

and attitudes, educate, reassure the patient, and reinforce the patient-clinician partnership

Emphasize non-drug treatments as well as drug treatments: CBT, graded aerobic exercise, tricyclics for FM

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MUS – Sample recommendations

Grade B: Recommended:Early intervention may improve prognosisSSRIs, NSAIDs may have some benefitAcupuncture, biofeedback, stretching

possibly of benefit

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MUS – Sample recommendations

Grade C: “Consider for some”Relaxation responseFlexibility programs when combined with

aerobic exerciseMassageSSRI

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MUS – Sample recommendations

Recommendations D/E: “Beware”:XanaxAntibioticsProlonged Bed restCorticosteroidsFlorinef (alone)

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Future Vision

Through partnerships with other agencies and health systems, develop accelerated process for evidence synthesis and guideline development

Sharpen focus on deployment health issues Incorporate patient preferences* Consider newer approaches to assessing evidence and

strength of recommendations (GRADE) Strengthen links between Clinical Practice Guidelines and

Performance Metrics Embed the guidelines and the measurement into clinical

work using the EHR

* see Krahn, JAMA 2008;300:436