February 2019, Volume XXXII, No 11
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.
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.
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.
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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