May 2019, Volume XXXIiI, No 2

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Evidence synthesis

Improving outcomes, avoiding waste

he amount of information available to make health care decisions is enormous and changing rapidly. Clinicians, health systems, policy makers, researchers, and patients often find it difficult to identify the “right information” about the effects of health care interventions. These medical information “end-users” increasingly rely on systematic reviews and corresponding clinical guidelines to provide trusted health care information.

For more than 20 years, clinicians and researchers at the Minneapolis VA Evidence-based Synthesis Program (ESP) and other evidence synthesis teams at the VA and the University of Minnesota have conducted and disseminated systematic reviews of health care interventions for high priority clinical topics. In this article, we describe our Minneapolis VA ESP processes and products, highlight examples of recent and ongoing reviews, and discuss future challenges and opportunities, with suggestions to assist readers in utilizing findings to improve health care quality.

Evidence synthesis at the Minneapolis VA Health Care System

The Minneapolis VA ESP is comprised of a multidisciplinary group of clinicians and researchers with expertise in health care practice, policy, and research. The ESP receives funding from the VA Quality Enhancement Research Initiative and is under the direction of Timothy Wilt, MD, MPH, general internist and health services researcher and professor of medicine at the University of Minnesota. The ESP is one of four nationally funded VA programs and part of the Minneapolis VA Center for Care Delivery and Outcomes Research, a VA national Health Services Research and Development Center of Innovation. Our evidence teams prepare rigorous, readable, and relevant syntheses of published scientific literature and make their findings available to clinicians, managers, and policymakers to improve the health of Veterans and others. Nancy Greer, PhD, is the ESP program manager, and Wei (Denise) Duan-Porter, MD, PhD, is associate director.

In addition to VA reports, our evidence team conducts reviews funded by and designed to inform clinical practice guidelines for multiple medical organizations, including the American College of Physicians, the American Urological Association, and the National Kidney Foundation. We also support reviews initiated by clinicians, health care systems, and researchers to improve care quality or serve as foundations for research grant applications.

Evidence synthesis and methods work is often conducted in collaboration with other evidence reviewers, including Philipp Dahm, MD, MHSc, coordinating editor of Cochrane Urology (Urology Section). Dr. Dahm and Shahnaz Sultan, MD, MHSc (Gastroenterology Section) are international leaders in evidence review methodology. As members of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Network, they provide national training and mentorship in systematic reviews and evidence-based health care. We also partner with the University of Minnesota School of Public Health as the Agency for Healthcare Research and Quality (AHRQ)-funded Minnesota Evidence-based Practice Center (EPC), co-directed by Dr. Wilt and Mary Butler, PhD, MBA, associate professor of the School of Public Health.

Patient data … can lead to meaningful improvements in patients’ experiences and health.

Background on evidence synthesis programs

ESPs produce and disseminate systematic reviews of existing evidence to: identify effective services to improve patient outcomes; avoid ineffective, wasteful, and potentially harmful care; support development of evidence-based policies, practice guidelines, and performance measures; and set the direction for future research to address knowledge gaps. ESPs help VA fulfill its vision of functioning as a “learning healthcare system” to improve Veterans’ health and health care. ESP teams are comprised of a core group of individuals with expertise in systematic review methodology complemented by project-specific content experts. ESP members provide disclosures and are not permitted to have significant scientific or financial conflicts of interest.

Topics are nominated by clinical and policy stakeholders, who help refine key questions to ensure they are clinically useful while remaining manageable in scope. Questions are developed to address clinical benefits, harms, and costs, as well as implementation barriers and facilitators using a PICOTS framework (Patient, Intervention, Comparator, Outcomes, Timing, and Setting). ESP reports begin with executive summaries highlighting key findings. Full reports include detailed methodological information, results, and discussion of research gaps and policy implications. Reports undergo peer review with a focus on highlighting findings useful for clinicians and policy makers.

Technical reports are available online throughout the VA and in the public domain, and summaries are often published in medical journals and presented in national VA Cyberseminars. “Management e-Briefs” are prepared to provide succinct nontechnical information to VA management and policy leaders, enhancing implementation. Project timelines range from several months to one year.

Evidence reports and their impact on health care practice and policy

Four examples highlighting the range of topics and health care impacts:

The utility of screening pelvic examinations. While more than 60 million pelvic examinations are conducted each year, often as part of a general wellness exam, the utility of the pelvic exam is not known. The VA Office of Health Promotion and Disease Prevention and the Women’s Health Network requested a review evaluating the diagnostic accuracy, clinical benefits, and potential harms of the pelvic examination in asymptomatic, nonpregnant women. Led by Hanna Bloomfield, MD, MPH, results from 52 studies found no data supporting the use of pelvic examination in asymptomatic, average-risk women. Low-quality data suggested that pelvic examinations may cause pain, discomfort, fear, anxiety, or embarrassment in about 30 percent of women. Report findings led to VA clinical guidance statements. The American College of Physicians subsequently developed clinical guidelines recommending against performing screening pelvic examinations in asymptomatic, nonpregnant women.

Evaluating pharmacist-led care. Pharmacists have expanded their involvement in patient care, including independent prescribing privileges. This may increase access, improve outcomes, and lower costs. The VA National Clinical Pharmacy Research Group and Pharmacy Benefits Management program requested an evaluation of the effectiveness and harms of pharmacist-led chronic disease management, which may include medication monitoring, medication therapy review, prescribing authority, and/or disease self-care and support. The report, led by Dr. Greer in collaboration with Jennifer Bolduc, PharmD, focused on pharmacist-led care for patients with diabetes, hypertension, and lipid disorders, comparing outcomes with those of patients who did not participate in pharmacist-led care (defined in the report as “usual care”).

Data from 63 studies indicated that pharmacist-led care, when compared with usual care, was associated with comparable numbers of visits to primary care offices, urgent care, or emergency departments; hospitalizations; and medication adherence. Pharmacist-led care increased the number or dose of medications received and improved glycemic, blood pressure, and lipid goal attainment. Mortality and clinical events were similar. Evidence on patient satisfaction was mixed. Further research is needed to determine whether pharmacist-led care improves clinical outcomes. The results support health systems expanding the role of pharmacist-led care, especially if targeted intermediate goals have demonstrated beneficial outcomes.

Rigorous reports that do not align with clinical and policy needs are not useful.

Chronic musculoskeletal pain scales. Chronic musculoskeletal pain is a major source of disability and morbidity. Management remains challenging and pain experts have called for more strategic pain therapy research. A VA State of the Art Conference on chronic musculoskeletal pain management and the VA Pain Measurement Outcomes Workgroup requested a review describing existing research on key psychometric properties of self-report measures of pain severity and functional impairment. To address their needs in the rapid time frame required, we conducted a “rapid review and evidence map.” We developed this approach to illuminate the research gaps and data synthesis challenges. Led by Elizabeth Goldsmith, MD, PhD, we found that five measures had the most evidence, though there was substantial variation in estimating psychometric properties, defining chronic musculoskeletal pain, and reporting patient demographics. Further research is needed to validate patient-reported pain outcome measures in populations with chronic musculoskeletal pain.

Preventing long-term nursing home placement. Nursing-home placement has high financial and social costs. Identifying modifiable determinants of, and interventions to reduce, long-term nursing home placement can improve patient- and caregiver-centered outcomes and reduce health care costs. An ongoing review, led by Wei (Denise) Duan-Porter, MD, PhD, is intended to enhance national VA program policies and practices to optimize the ability of Veterans to remain in their own homes if desired.

Challenges and opportunities

Evidence synthesis teams must overcome future challenges. These include incorporating advances in systematic review methodology and enhancing results communication. Reducing the overabundance of systematic reviews that are scientifically flawed or conducted by groups with strong conflicts is required because they can lead to biased and contradictory findings not easily discerned. This can result in distrust in “evidence-based” health care, in part because evidence reports require numerous decisions to efficiently summarize original research. These decisions should be transparent and defendable. (See sidebar for questions to ask when critically appraising systematic reviews.)

However, rigorous reports that do not align with clinical and policy needs are not useful. Future evidence synthesis team roles include assisting partners to identify steps required for reliable evidence reports, as well as where and if additional value lies in conducting a report. Evidence reports must increasingly be responsive to rapid advances in medicine and end-users’ timelines. Tradeoffs between “scientific thoroughness” and timeliness are required, though large consequences exist with flawed shortcuts because evidence reports inform practice implementation and performance measurement development. “Socializing” evidence reports and carefully engaging in “informed speculation” is challenging, but allows evidence reports to serve as a trustworthy “bridge” between rigorous, refined research settings and unique day-to-day patient care experiences. As the amount of knowledge and needs of stakeholders expands, “living guidelines” with continuous evidence updates or searches for signals of important new information will be required so that review findings remain up-to-date.

Despite these challenges, numerous opportunities exist. Clinicians will increasingly need accessible, reliable evidence to address questions relevant to their patients. Health care systems will seek guidance on local policy and purchasing decisions; e.g., should they design and put into place new multicomponent pathways for post-operative care and, if they do, what implementation barriers and facilitators exist; are the benefits of selected technologies worth the upfront and downstream harms and costs; what are the comparative trade-offs when selecting among different medications for inclusion on a pharmacy formulary; can “smart” electronic reminder systems be established to enhance personalized care quality based on reliable evidence of benefits and harms and, if so, how will they be used to derive and monitor pay-for-performance? Researchers and funders will want to know what evidence gaps exist and the types of research needed to close clinically important gaps.

Rigorous, readable, relevant (and timely) systematic reviews and their accompanying practice guidelines will increasingly be valuable resources to help fill these needs. The Minneapolis VA ESP and other Minnesota evidence synthesis groups welcome opportunities to assist stakeholders define, discover, and deliver high value health care.

Questions to ask when critically appraising systematic reviews

Do the key questions address the clinical situation relevant to my patients and practice?

Was the literature search comprehensive and up-to-date?

Are clinical benefits and harms, including costs and burden, adequately considered?

Are results presented in absolute as well as relative terms?

Are important patient and condition subgroups evaluated (e.g. age, sex, race, condition severity, and comorbidities)?

Is there an assessment of individual study quality and overall results’ certainty?

Are the conclusions justified by the results?

Are conflicts of interest (including the funding source) disclosed and could they affect the findings and conclusions?

Timothy Wilt, MD, MPH, is a general internist and health services researcher at the Minneapolis VA Center for Care Delivery and Outcomes Research and professor of medicine at the University of Minnesota. He is the director of the Minneapolis VA Evidence-based Synthesis Program and co-director of the Minnesota AHRQ-Evidence-based Practice Center. Dr. Wilt’s clinical and research interests are in health promotion and disease prevention, detection, and treatment, with an emphasis on enhancing high value care and reducing low value care.

Wei (Denise) Duan-Porter, MD, PhD, is a general internist at the Minneapolis VA Health Care System, health services researcher at the Minneapolis VA Center for Care Delivery and Outcomes Research, and assistant professor of medicine at the University of Minnesota. She is the associate director of the Minneapolis VA Evidence-based Synthesis Program. Her research has focused on improving patient-centered outcomes and quality of care for medically complex older adults.

Nancy Greer, PhD, is a health science specialist at the Minneapolis VA Center for Care Delivery and Outcomes Research. She is the program manager for the Minneapolis VA Evidence-based Synthesis Program (ESP) and project manager for ESP and other evidence review projects, overseeing a team of project coordinators and research assistants. She has conducted and led evidence reports across a wide range of health care topics 

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Nancy Greer, PhD, is a health science specialist at the Minneapolis VA Center for Care Delivery and Outcomes Research. She is the program manager for the Minneapolis VA Evidence-based Synthesis Program (ESP) and project manager for ESP and other evidence review projects, overseeing a team of project coordinators and research assistants. She has conducted and led evidence reports across a wide range of health care topics