Evidence-Based%20Clinical%20Practice%20Guidelines%20in%20the%20Veterans%20Health%20Administration - PowerPoint PPT Presentation

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Title: Evidence-Based%20Clinical%20Practice%20Guidelines%20in%20the%20Veterans%20Health%20Administration

Evidence-Based Clinical Practice Guidelinesin
the Veterans Health Administration
  • David Atkins, MD, MPH
  • Health Services Research and Development
  • Quality Enhancement Research Initiative
  • Dept. of Veterans Affairs

  • Briefly review the joint VA/DOD guideline
    development effort
  • Describe the role of guidelines in system-wide
    quality improvement
  • Reflect on future challenges and implications for
    guideline development
  • Guideline development process
  • Guideline products

Guidelines in The VA Health System
  • VA is a user and developer of guidelines
  • Integrated health system serving 5 million
  • 200,000 employees
  • Collaborates with Dept. of Defense to develop
    common guidelines for active duty and retired
    service members

VA/DoD Executive Council
VA/DoD EBP Working Group
Veterans Affairs
Quality Management
COL Doreen Lounsbery, MD, Office of
Evidence-Based Practice
CAPT Neal Naito MC, Navy Clinical Plans
Joe Francis, MD, VA Office of Quality
Col Erika Barger, MC, Air Force Medical
Operations Agency
Goals of VA/DoD Evidence-based Guidelines
  • Summarize evidence and recommendations that can
    form the basis of clinical policy and delivery
    system design
  • Create tools that assist clinicians and managers
    in implementing evidence into practice
  • Guide local quality improvement efforts
  • Reduce waste inappropriate variation
  • Enhance population health

Why a VA/DoD Guideline Development Process?
  • Allows tailoring to the needs of the current or
    former service member
  • may assist seamless transition
  • Provides check on Industry Professional Group
  • Strong adoption of evidentiary standards
  • Focus on primary care
  • Use of algorithms and other tools to assist
  • Enhances ability to drive clinical policy

VA/DoD CPGs Available for Use
Posted to www.Guideline.gov (National Guideline
Clearing House)
  • Asthma
  • Amputation Rehabilitation
  • Chronic Heart Failure
  • Chronic Obstructive Pulmonary Disease
  • Diabetes Mellitus
  • Dyslipidemia
  • Dysuria in Women
  • Erectile Dysfunction
  • GERD
  • Hypertension
  • Ischemic Heart Disease
  • Kidney Disease
  • Low Back Pain
  • Major Depressive Disorder
  • Management of Tobacco Use
  • Medically Unexplained Symptoms Chronic Pain
  • Opioid Therapy for Chronic Pain
  • Obesity
  • Post-Operative Pain
  • Post-Deployment Health
  • Screening Health Exam
  • Post-Traumatic Stress Disorder
  • Psychosis
  • Stroke Rehabilitation
  • Substance Use Disorder
  • Uncomplicated Pregnancy

also Biological, Chemical, and Radiation-Induced
Illnesses Pocket Cards
Whats Different About the VA/DoD?
  • Integrated Health Systems
  • Mission-driven culture
  • Strong emphasis on primary care
  • Wide-spread electronic health record
  • Ten year experience with a robust set of
    performance metrics

Evidence as the Basisfor Clinical Policy
Whats Improved
  • Greater use of systematic reviews
  • More explicit presentations of evidence
  • More explicit designation of when evidence is
  • ? Multidisciplinary representation

Problems with Guideline Development Development
  • Process still too inefficient
  • Effort not always matched to value redundancy
  • Conflict of interest persists
  • Not solved by disclosure alone
  • Too much effort on less important areas
  • Too little attention to harms, tradeoffs
  • Panels often dont reflect the targets audience
    of guidelines
  • Primary care under-represented
  • Patient representation challenging

(No Transcript)
Problems in Guideline Presentation
  • Is goal to write a textbook or improve care?
  • Little distinction between recommendations with
    widely varying health impact
  • Not written with translation to tools in mind
  • Computerized decision support
  • Performance measures
  • Coverage decisions
  • Limited attention to costs, feasibility, or
    patient values
  • Often contribute to misguided attempts to
    dichotomize quality of care good vs. bad

Future Challenges
  • Tensions between practical guidance vs.
    individualized care
  • Benefits of many recommendations depend
    critically on individual characteristics (e.g.
    lipids, osteoporosis)
  • Role of age, co-morbidity, poly-pharmacy
  • How can guidelines better promote progress
    towards goal vs. arbitrary goal?
  • Recognizing system factors and implementation
  • Are there practical ways to incorporate patient
  • Coordination across different groups

  • Strong policies on conflict of interest
  • Open peer review
  • Reduce specialty dominance in developing
    guidelines aimed at primary care
  • Address tradeoffs in recommendations
  • Preferences, costs, feasibility
  • Consider system and implementation factors
  • Specific language to identify target population
    and actions
  • Avoid black/white definitions of success
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