1 evidence based practice in vha presentation to the advisory committee on gulf war veterans joseph...
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1
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
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