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Research Highlights
Leading the charge toward evidence-based medicine
November 25, 2008
Think of them as the Sherlock Holmes
of VA research.
Since 2007, two groups of VA
investigators—one in California, the other
in Oregon—have been tackling tough and
timely research questions of particular
importance to VA policymakers. The
researchers are part of the Evidence
Synthesis Program (ESP) funded by VA
Health Services Research and Development.
Like detectives, ESP investigators comb
through evidence—in this case, published
research findings. They look for clues others
may have missed. They rigorously evaluate,
analyze and synthesize data. They uncover
previously unrecognized patterns and reveal
new insights. Their goal is to provide the
best possible information to guide medical
care. The end product is a comprehensive,
incisive report that gets disseminated widely
within VA, primarily to top health care
planners and managers. The reports also get
published in the general medical literature
for clinicians worldwide to learn from.
Reports available online
So far, seven ESP reports have been
completed. Veterans and the general public
can see them at http://www.hsrd.research.va.gov/
publications/esp. The topics are diverse, but
all are strongly relevant to veteran care:
pain in polytrauma patients; high blood
sugar or pain in hospital patients; racial and
ethnic disparities in care; and others.
Joseph Francis, MD, MPH, deputy
director of VA's Office of Quality and
Performance, says his and other offices
within the Veterans Health Administration
rely on ESP for guidance.
"As we reshape our policy initiatives to
be more evidence-based, one cannot
overstate the importance of a thorough,
unbiased assessment of the medical
literature," says Francis. "Many of the key
questions facing VHA—how to address
suicide risk, manage polytrauma, or reduce
health disparities—require a balanced
approach to identify, evaluate and
summarize relevant scientific studies so that
appropriate treatment guidelines or policies
can be formulated. ESP has contributed to
all of these, and its importance is growing."
According to David Atkins, MD, MPH,
associate director for Health Services
Research and Development, ESP has helped
improve care in VA and beyond. A report on
osteoporosis in men not only led to new
screening procedures in VA but helped
change the clinical guidelines of the
American College of Physicians. Another
on drug therapy for a common prostate
condition led to changes in which
medications are available to VA patients. And a report on women's health was
"incorporated into the national agenda for
reforming the delivery of care to women
veterans," says Atkins.
Francis notes that "ESP is a wonderful
means for researchers to interface with the
VA health care system and see their efforts
have a direct impact on care."
Program builds on existing
infrastructure
Mark Helfand, MD, MPH, MS, leads the
ESP team based at the Portland VA Medical
Center. His counterpart at the VA Greater
Los Angeles Healthcare System is Paul
Shekelle, MD, PhD. Both VA physician researchers
also lead Evidence-based
Practice Centers funded by the federal
government's Agency for Healthcare
Research and Quality (AHRQ). Those
centers, 14 in all nationwide, do work similar to what ESP does, but
on a broader scale—the focus is not health care for veterans but for
Americans in general. Rather than duplicate what AHRQ has done
with its evidence centers, VA "buys time" from these centers—in
effect, building on staff and expertise already in place. The
collaboration is a prime example of federal agencies leveraging
their resources.
"VA is taking advantage of the infrastructure that AHRQ built—
that's what makes this program possible," says Helfand. "If we had
to have all the trained librarians and research associates and other
resources required to do this work, there would be a much larger
cost to VA for the same product."
Helfand also points out another way in which taxpayer dollars
are well-spent through ESP.
"If VA is asking us, what's out there that really works that we
should be doing in VA, we don't have to review the primary
literature ourselves. We can start by using other researchers'
systematic reviews and evidence reports. We evaluate their quality,
their thoroughness, their relevance to the questions that VA has
asked. Then we can supplement by updating the evidence with the
most current information and further evaluating how it all applies
to VA settings and populations."
Helfand emphasizes that ESP reports go broader and deeper than
other types of literature reviews.
"There's a lot of terminology out there. Most people think of a
systematic review as a narrowly defined review of randomized
clinical trials. That's something we're rarely asked to do. We're
usually asked to look at a much wider scope of evidence."
As an example, he cites his team's recent report on pain in
polytrauma patients. "We went so far beyond that narrow notion of
the systematic review," says Helfand. "We looked, for instance, at
case reports—single examples of something that may have helped
in what can be a frustrating or desperate situation. Not to say that
something definitely works, or is effective, but to help guide VA's
future research and orient it toward promising innovations."
That aspect of ESP—its ability to pinpoint critical issues
requiring further study—makes it especially valuable to the overall
VA research program.
"We're very proud of the work they're doing," says Seth Eisen,
MD, MSc, director of Health Services Research and Development.
In addition to informing VA policymakers, says Eisen, the ESP
reports "help identify the the next issues that need to be addressed
through research."
This article originally appeared in the Nov/Dec 2008 issue of VA Research Currents.
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