HSR&D: “Hotbed of Comparative

Effectiveness Research” HSR&D: “Hotbed of Comparative

Effectiveness Research” 30 Years of VA Comparative Effectiveness

Research: September 23, 2009

Seth Eisen, MD, MSc, Director, HSR&D

What I Will Say

• Health Services Research is “bedside” research for health systems

• Most health systems questions involve comparing different options.

• Many priority comparative effectiveness questions are health system questions o (23 of 100 IOM priorities)

• A majority of VA’s HSR portfolio involves CER

Why is HSR Essential To CER Portfolio

• Assesses “effectiveness” in real-world settings with representative population

• Examines comparative questions that are difficult to answer in prospective RCTo Timing, technology, study size, harms

• Studies CER questions that relate to organization and delivery of care

HSR&D’s CER Strengths: Human

Capital

• Research priorities that emphasize quality of care for Veterans

• Clinician-investigators challenged by CER questions arising in practice

• Decades of tradition of research collaboration across medical centers

• Research career mentorship program that supports MD & non-MD clinical investigators

Human Capital HSR&D Research Priorities:

Disease Oriented:• Post Deployment Health (TBI, polytrauma, pain)• Mental Health (PTSD, substance abuse, suicide)• Care of Complex, Chronic Conditions• Health Services GenomicsSociological & Cultural:• Health Equity & Disparities • Long-Term Care & Caregiving• Access/Rural HealthMethodological:• Healthcare Informatics • Education to improve outcomes• Implementation (QUERI)

Human Capital Research Mentorship

Program:

• Strong mentorship required • 5 years salary + research support • Broad specialty spectrum eligible• ~ 60 current awardees

HSR&D’s CER Strengths: Research

Infrastructure• Core funding for 27 VAMC research

centerso Varied areas of focus (e.g. Acute Care,

Mental Health, Chronic Care, Primary Care, Equity)

• 3 Resource Centerso Economics, Data, Dissemination

• Vast data resources• Advanced electronic medical record

o Points of care ~ 1500o Patients treated ~ 5.6m/yr (~

250k/day) o Employees ~ 232k (~15k MD’s,

~60k RN’s)o Outpatient Encounters: ~ 68m

(~0.5m/day)o Inpatient Discharges: ~ 600k/yr (~

2k/day)o Pharmacy Fills: ~245m/yr (~

700k/day)o Chemistry Lab Tests: ~ 240m/yr (~ 700k/day)o Radiology Procedures: ~ 10m/yr (~

30k/day)

Research InfrastructureVolume of VA Clinical

Care

Clinical Reminders Appointments

Problem List

CODED ENTRIES

• Demographics• Vitals• Allergies• Problem List & diagnoses• Inpatient / Outpatient

Orders• Inpatient / Outpatient

Pharmacy• Outpatient “Stops”• Chemistry Lab• Blood Bank Lab• Autopsy Lab • Immunizations• Clinical Reminders• Patient Education• Prosthetic Devices

TEXT ENTRIES

• Inpatient / Outpatient Provider Notes

• Dental Notes • Nursing Notes• Homecare Notes • Nursing Home Notes• Consult Requests &

Responses• Surgical Notes / Reports• Clinical Procedures• Dietetics Notes • Radiology Reports• Pathology Reports• Compensation and Pension

Exams

Research Infrastructure

Comprehensive EHR Data Domains

DiabetesDiabetesCare ManagementCare Management

Data MartData Mart

Diabetes ResearchDiabetes ResearchData MartData Mart

DataDataWarehouseWarehouse

Health DataHealth DataRepositoryRepository

SourceSourceSystemsSystems

AcquireAcquire Populate Populate CreateCreate Access Access Data Data Warehouse Warehouse DatabasesDatabases Information Information

11 33 44

Common Query, Reporting, Common Query, Reporting, Analysis, & Data Mining ToolsAnalysis, & Data Mining Tools

22

Research Infrastructure

VHA Data Warehouse:

Clinical Care Management Site

Research siteUpdated continuously

Care ManagementCare Management

ResearchResearch

DataDataWarehouseWarehouse

AdministrativeAdministrative(DSS, PBM, etc.)(DSS, PBM, etc.)

OtherOther(Medicare, DoD)(Medicare, DoD)

“There are two equally effective ways of being keptin the dark. One is to have too little information. The other, ironically, is to have too much.”

Modified from “Building Better Boards,” David A. Nadler, Harvard Business Review, May 2004

CER Examples:CER Examples:

• Impact of change in resident duty hours on patient safety indicators. Rosen et al, Medical Care, 09

• Impact of veteran prescription copayment increase on medication adherence. Doshi et al, Circulation, ‘09

• Impact of integrated HIV care on successful viral suppression. Hoang et al, Medical Care, ‘09

• Impact of optimized antidepressant therapy & pain self management on depression and pain reduction. Kroenke et al, JAMA, ’09

• Teledermatology accuracy. Warshaw et al. J Am Acad Derm, ‘09

• HBP self management impact on HbA1C. Powers et al, Am J Med, ‘09

Conclusions

VHA-Based CER

• Established research teams and infrastructure facilitate timely research

• Tradition of collaboration facilitates multi-center research and improved methods

• Research career mentoring program produces CER-trained investigators

• National IRB facilitates multicenter CER trials

National Lessons from VHA-Based CER

VHA’s advanced EHR facilitates:• Identification & recruitment of

research subjects • Data access & collection of outcome

information • Utilization of data & information

derived from text processing to CER

National Relevance of VHA- Based CER

• Many of HSR&D’s research priorities are the nation’s priorities

• VHA can function as a ‘CER Laboratory’, free from fee-for-service related issues

• VHA’s integrated health care facilitates comparisons of alternate systems of care

“Bottom Line”

HSR&D’s Human Capital & Research Infrastructure provides opportunities for

conducting CER that is :

•Timely•Addresses broad array of outcomes•Makes innovative use of informatics•Uses observational & randomized designs•Relevant to health systems