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

1. 1 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

2. 2 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

3. 3 Organization structure of the EBP WG with its five subgroup. The subgroups execute the actual work of the EBPWG. Their charge is to: - Facilitating ongoing development of evidence-based clinical advances into practice - Adapt, adopt, develop implement & sustain evidence-based clinical guidelines - Foster integration of evidence-based practice into VA/DoD initiatives related to health promotion, disease prevention, and wellness initiatives - Assess the effectiveness of implementation & make recommendation for maximize performance improvement - Champion integration of guidelines into current developing information systems - Identify opportunities to make recommendation for research related to evidence-based practice within VA/DoD Organization structure of the EBP WG with its five subgroup. The subgroups execute the actual work of the EBPWG. Their charge is to: - Facilitating ongoing development of evidence-based clinical advances into practice - Adapt, adopt, develop implement & sustain evidence-based clinical guidelines - Foster integration of evidence-based practice into VA/DoD initiatives related to health promotion, disease prevention, and wellness initiatives - Assess the effectiveness of implementation & make recommendation for maximize performance improvement - Champion integration of guidelines into current developing information systems - Identify opportunities to make recommendation for research related to evidence-based practice within VA/DoD

4. 4 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: 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 VA Membership issues: New Chief Quality officer Dr Steve Fihl, ask that his deputy Dr Joe Francis be co-chair of the workgroup. CDR McBreen has asked to be replaced by CDR Von Thun (Navy Rep) The VA/DoD EBPWG has enters several partnership this year with other National Guideline Developers 1. Interorganoizational Guideline Forum With Kaiser Permanente, Institute for Clinical System Improvement (ICSI), Geisenger Health Plan 2. American Heart Association. In 2005 the AHA adopted the VA/DoD Stroke Rehabilitation Guideline as asked to work with us on the current update that is in progress. 3. American College of Physicians Work group provided panel members in the creation of the LBP CPG. Continue relationship with review of ACP guidelines and discuss further collaborations VA Membership issues: New Chief Quality officer Dr Steve Fihl, ask that his deputy Dr Joe Francis be co-chair of the workgroup. CDR McBreen has asked to be replaced by CDR Von Thun (Navy Rep) The VA/DoD EBPWG has enters several partnership this year with other National Guideline Developers 1. Interorganoizational Guideline Forum With Kaiser Permanente, Institute for Clinical System Improvement (ICSI), Geisenger Health Plan 2. American Heart Association. In 2005 the AHA adopted the VA/DoD Stroke Rehabilitation Guideline as asked to work with us on the current update that is in progress. 3. American College of Physicians Work group provided panel members in the creation of the LBP CPG. Continue relationship with review of ACP guidelines and discuss further collaborations

5. 5 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

6. 6 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

7. 7 Evidence as the Basisfor Clinical Policy

8. 8 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

9. 9 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)

10. 10 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

11. 11

12. 12 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

13. 13

14. 14

15. 15 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

16. 16

17. 17

18. 18 MUS � Sample recommendations Grade A: Strongly recommended Validate 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

19. 19 MUS � Sample recommendations Grade B: Recommended: Early intervention may improve prognosis SSRIs, NSAIDs may have some benefit Acupuncture, biofeedback, stretching possibly of benefit

20. 20 MUS � Sample recommendations Grade C: �Consider for some� Relaxation response Flexibility programs when combined with aerobic exercise Massage SSRI

21. 21 MUS � Sample recommendations Recommendations D/E: �Beware�: Xanax Antibiotics Prolonged Bed rest Corticosteroids Florinef (alone)

22. 22 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