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Evidence-based Synthesis Program
The Evidence-based Synthesis Program (ESP) was established to provide timely and accurate
syntheses of targeted health care topics of particular importance to VA managers and policy makers
and to disseminate these reports broadly throughout VA. Available reports are listed and linked below.
Hyperglycemia is a common finding in hospitalized patients and has been associated with worsened outcomes in a variety of inpatient subpopulations. The use of insulin to control blood glucose has been advocated as a way to improve health outcomes in hospitalized patients with hyperglycemia, but the evidence for the efficacy of this approach and the thresholds for initiating insulin management are unclear.
The key questions were:
- Does strict blood glucose control compared to less strict blood glucose control improve final health outcomes in the following patients?
- patients in the medical intensive care unit
- patients in the surgical intensive care unit
- acute myocardial infarction patients
- acute stroke patients
- post coronary artery bypass graft patients
- general surgical ward patients
- general medicine ward patients
- What are the harms of strict blood glucose control in the above subpopulations?
- What are the most effective and safest means of normalizing blood glucose in the above subpopulations?
(749 KB, PDF)
- Appendix D (87 KB, MS Excel)
- Appendix E (81 KB, MS Excel)
Pain resulting from polytraumatic injuries poses numerous challenges during and after
rehabilitation treatment. The objectives of this report are to systematically review the
literature to address the assessment and management of pain in patients with
polytraumatic injuries, to identify patient, clinician and systems factors associated with
pain-related outcomes in these patients, and to describe current or planned research
addressing the key questions in this report. The key questions were:
- Have reliable and valid measures and assessment tools been developed to measure
pain intensity and pain-related functional interference among patients with
cognitive deficits due to TBI? Which measures and tools are likely to be most
useful in assessing pain in polytrauma patients with cognitive deficits due to TBI?
- What patient factors are associated with better and worse pain-related clinical
outcomes among polytrauma patients? Have interventions been developed to
specifically address these factors?
- What are unique provider and system barriers to detecting and treating pain among
polytrauma patients? Have interventions been developed to effectively address
these barriers?
(770 KB, PDF)
- Appendix D - Reviewer comments and responses (91 KB, MS Excel)
- Appendix E - Evidence Table 1 -
Studies on patient factors associated with polytrauma outcomes (132 KB, MS Excel)
- Appendix E - Evidence Table 2 - Active research projects (60 KB, MS Excel)
The prevalence of pain on the inpatient medical ward is lower than that of a surgical service, but is still substantial. A systematic review was conducted, including an integration of the existing literature on the delivery of effective pain care in the acute care setting, to inform the VA's National Pain Management Strategy and the VA's pain research agenda. The key questions addressed were:
- For inpatients who have acute pain, how do differences in timing and frequency of assessment, severity of pain, and follow-up of pain affect choice of treatment, clinical outcomes, and safety?
- How do the timing and route of administration of pain interventions compare in effectiveness, adverse effects, and safety in these inpatient care settings?
- For inpatients with impaired self-report due to any of several factors, including delirium or confusion, pre-existing severe dementia, closed head injury, stroke, and psychosis, how do differences in assessment and management of acute pain affect clinical outcomes or safety?
- For inpatients with dependencies on tobacco, alcohol, stimulant, marijuana, or
opioids, how do differences in assessment and management of acute pain affect clinical
outcomes or safety? How do the assessment and management of acute pain differ
between patients on prexisting opioid therapy and patients with opiate addiction?
(759 KB, PDF)
- Appendices A, B, C, and E (153 KB, PDF)
- Appendix D - Evidence Summary Tables (44 KB, MS Excel)
Diabetes is a prevalent and costly disease in Veterans. Control of blood glucose is an important VA objective. Self-monitoring of blood glucose (SMBG) is advocated as a method to better achieve control. The Key Questions investigated in this report were:
- Is regular SMBG effective in either achieving or maintaining target A1c levels for patients with type 2 diabetes?
- Does regular SMBG reduce the frequency of hypoglycemia in patients with type 2 diabetes?
- Is there evidence that different frequencies of testing result in differences in improvements in A1c?
(680 KB, PDF)
Numerous studies have demonstrated racial and ethnic disparities in
health care in the United States. These disparities have been demonstrated in
the Veterans Affairs (VA) healthcare system, where financial barriers to
receiving care are minimized. The VA is committed to delivering high-quality
care in an equitable manner, and as such, to eliminating racial and ethnic
disparities in health care. To inform this effort,
the existing evidence on disparities within the VA was systematically reviewed, to address the following objectives:
- Determine in which clinical areas racial and ethnic disparities are prevalent within the VA;
- Describe what is known about the sources of those disparities; and
- Qualitatively synthesize that knowledge to determine the most promising avenues
for future research aimed at improving equity in VA health care.
(868 KB, PDF)
- Appendix IV - Evidence Tables (535 KB, MS Excel)
Although 25% of men over the age of 60 will sustain osteoporotic fractures during their lifetime,
data suggest that male osteoporosis is underdiganosed and undertreated. In order to help inform
decisions about whether the Veterans Health Administration should develop screening guidelines
for male osteoporosis, the following Key Questions were analysed in this report:
- What are the prevalence of and risk factors for osteopenia, osteoporosis and
osteoporotic fractures among men in general and among male Veterans specifically?
- Are there any validated tools (outside of central bone density) to screen for osteoporosis in men?
- What values of bone mineral density (BMD) determined by Dual energy X-ray Absorptiometry (DXA)
(and by different DXA techniques) have been used to diagnose osteopenia and osteoporosis; and
what is the evidence regarding the relationship between differing definitions and the development
of osteoporotic fractures?
(800 KB, PDF)
Benign prostatic hyperplasia (BPH) causes urinary hesitancy and intermittency, weak urine stream,
nocturia, frequency, urgency, and the sensation of incomplete bladder emptying. These symptoms,
collectively called "lower urinary tract symptoms," or LUTS, can significantly reduce quality of life.
Depending upon the severity of sypmtoms, men may be managed without pharmacotherapy, or they may
require medical treatments of drugs from two main classes. This Evidence Synthesis Report addresses
the following questions about treatment for BPH:
- For patients with BPH, what are the comparative benefits, harms, and efficacy of
combination therapy with a 5-alpha-reductase inhibitor plus an alpha blocker, versus either treatment alone?
- What are the comparative efficacy and harms of alpha-1-adrenergic antagonists?
- Are there subgroups of patients based on demographics (age, racial groups), other
medications, or co-morbidities for which one treatment is more effective or associated with fewer adverse events?
(1 MB, PDF)
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