Evidence Based Practice in VHA Presentation to the Advisory Committee on Gulf War Veterans

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Evidence Based Practice in VHAPresentation 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
Joint Executive Council Co-Chaired by VA DoD
Health Executive Council Co-Chaired by VA DoD
VA/DoD Evidence-Based Practice Workgroup Co-Chaire
d by VA DoD
Clinical Portfolio Management
Development Co-Chaired by VA DoD
Evidence-Based Knowledge Management
Transfer Co-Chaired by VA DoD
Decision Support Co-Chaired by VA DoD
Review Co-Chaired by
VA DoD
Evaluation Analysis Co-Chaired by VA DoD
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VA/DoD EBP Workgroup Members

• VA 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 HSRD
• 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 warrior
• may 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
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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 conditions
• most clinical trials exclude
• recommendations 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 dont 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 recommended
• Validate the patients 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 prognosis
• SSRIs, NSAIDs may have some benefit
• Acupuncture, biofeedback, stretching possibly of
  benefit

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MUS Sample recommendations

• Grade C Consider for some
• Relaxation response
• Flexibility programs when combined with aerobic
  exercise
• Massage
• SSRI

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MUS Sample recommendations

• Recommendations D/E Beware
• Xanax
• Antibiotics
• Prolonged Bed rest
• Corticosteroids
• Florinef (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 2008300436