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Comparative Effectiveness Research The New Imperative


  • pg 1
                                                              Translating research into quality health care for Veterans

M ay 2 0 0 9                                                  Commentary

                                                              Comparative Effectiveness Research—
                                                              The New Imperative
 Contents                                                     Peter L. Almenoff, M.D., FCCP, Assistant Deputy Under Secretary for Health for
                                                              Quality and Safety, VA Central Office, Washington, D.C.

                                                              Concern over accelerated health care costs      One of the hot new areas in research that is
 Director’s Letter                                      2
                                                              in the United States has increased sharply in   attempting to make an impact on improving
                                                              recent years. The per capita spending of        health care and controlling cost is compara-
 Response to Commentary                                 3

 Research Highlights                                          gross domestic product (GDP) in the             tive effectiveness. While there is no standard
 • HIV Rapid Testing                                    4     United States on health care is greater than    definition of comparative effectiveness as
                                                              any other developed country. In 2006, the       of yet, several definitions have been pro-
 • Future Prosthetic Costs                              5
                                                              United States spent $2.1 trillion, or 16 per-   posed by the Center for Medical Technol-
 • Readmission for Heart                                      cent of GDP, on health care. This figure        ogy Policy, Congressional Budget Office,
     Failure                                            6     translates to $7,026 per person annually, but   and the Institute of Medicine. The VA
                                                              unlike other developed countries that pro-      Office of Research and Development is
 • HSR&D 2009 National                                        vide near-universal coverage, 47 million        using the following working definition:
                                                              Americans (15.8 percent) lacked health
     Meeting                                             7
                                                                                                              Comparative effectiveness studies are studies that
                                                              insurance in 2006.
                                                                                                              provide information on the comparative benefits
                                                                                                              and/or harms of two or more alternative choices
                                                              One of the dominant drivers of rising
                                                                                                              for a given clinical condition, patient population,
                                                              health care costs is technology related
                                                                                                              or health care system. These choices can involve
                                                              changes in medical practice (38-62 percent).
                                                                                                              medications, invasive therapies, non-pharmacologic
                                                              Technology is pushed out into the field at
                                                                                                              treatments, diagnostic tests and strategies, models
                                                              an alarming rate often before it is ready for
                                                                                                              of care, or implementation strategies.
                                                              national deployment. Other factors that are
                                                              dramatically increasing health care costs in-
                                                                                                              Given this working definition, the minimum
                                                              clude prices in the health care sector (11-22
                                                                                                              criteria for comparative effectiveness studies
                                                              percent), personal income growth (11-18
                                                              percent), changes in third party payments
                                                              (10 percent), administrative costs (3-10        I Comparison of two or more alternative
                                                              percent), and aging of the population           approaches;
                                                              (2 percent).1                                   I Examination of patient outcomes (bene-
                                                                                                              fits and/or harms); and
                                                              At its current rate of increase, the rising
                                                              cost of health care will be unsustainable in    I Comparison between interventions,
                                                              the future. As a result of these driving        modalities of care, or system attributes that
                                                              forces, researchers are examining a variety     can affect care, but not among patient fac-
                                                              of approaches to controlling or decreasing      tors, or time periods.
                                                              health care costs.
  A publication of the VA Office of Research & Development,
  Health Services Research & Development Service, Center
  for Information Dissemination and Education Resources, in
  conjunction with AcademyHealth.
FORUM — Translating research into quality health care for Veterans                                                                                             2

                                                                                                      Clinical Effectiveness or Cost
  Director’s Letter                                                                                   Effectiveness?
                  This issue of FORUM focuses on the important topic of Com-                          There is current debate on whether federally-
                  parative Effectiveness Research (CER). Both clinicians and pa-                      funded comparative effectiveness research
                  tients appreciate the limited benchmarks available to inform                        should include consideration of cost effec-
                  clinical decisions and treatment options. Policymakers find                         tiveness as well as clinical effectiveness.
                  themselves in a similar situation—making health care legisla-                       Some of the main arguments against including
                  tion in an evidence vacuum. For clinicians, patients, and poli-                     questions of cost effectiveness in comparative
                  cymakers alike, however, CER has the potential to provide                           effectiveness studies are that cost structures
  much needed evidence-based criteria for health care decision-making.                                vary across health care plans and, as a result,
                                                                                                      findings might not be generalizable to
                                                                                                      different plans or geographic areas. In addi-
  Recently, CER activities have been expanding across the Federal Government. In

                                                                                                      tion, analysis of cost effectiveness might
  March 2009, the U.S. Department of Health and Human Services (HHS) estab-

                                                                                                      have a negative bias on the analysis of
  lished a 15 member Federal Coordinating Council for Comparative Effectiveness

                                                                                                      clinical effectiveness, leading to concerns
  Research (FCCCER). Supported by funding of approximately $1.1 billion, the FCC-

                                                                                                      that such analysis may result in restricted
  CER will help guide, prioritize, and coordinate comparative effectiveness research

                                                                                                      access to effective treatments. One advan-
  across HHS and the Departments of Veterans Affairs and Defense. Joel Kupersmith,

                                                                                                      tage of considering cost effectiveness in
  M.D., VA’s Chief Research and Development Officer, represents VA on the council.
  In other news, HSR&D gave a warm send off to Shirley Meehan who retired from                        federally-funded comparative effectiveness
  VA service on May 1. Dr. David Atkins, QUERI Director, will also serve as Acting                    research is that it would encourage greater
  Deputy Director of HSR&D until a new Deputy is named.                                               transparency and standardization in the
  And finally, I would like to note that we reviewed 124 proposals in the March                       methodologies used to determine cost.

                                                                                                      The dominant driver of health care cost is
  review, of which we expect to fund 32 projects. In addition, we reviewed 30 Career

                                                                                                      the expanding medical technology arena
  Development Award applications and we expect to fund seven. Congratulations

                                                                                                      where new modalities either fill a need for
  to all. Please keep your proposals coming.

                                                                                                      diagnosis and treatment, or replace older
                                                                                                      modalities that are cheaper. Newer tech-
  Seth A. Eisen, M.D., M.Sc.

                                                                                                      nologies have a large impact on health care
  Director, HSR&D

                                                                                                      spending in the United States because there
                                                                                                      are few requirements that effectiveness be
Comparative Effectiveness –                         analyses of claims records, however, is that      demonstrated before wide national imple-
Research Methods                                    such analyses do not account for patient          mentation. Newer technologies also have
Different research methods are available for        health status differences. Medical registries     the potential to increase applications where
the study of comparing effectiveness of             are developed to track patients with a simi-      therapy might not even be effective.
treatments. These methods include system-           lar disease or similar specific treatment.
atic reviews of existing research, analyses                                                           The Veterans Health Administration research
of claims records, analysis of medical              Randomized controlled trials are the              program offers an ideal home for studying
registries, randomized controlled trials, and       most definitive way to compare different          comparative effectiveness. We are a large
computer modeling. Each of these methods            treatments but are generally very expensive       integrated health care system with an elec-
offers benefits and drawbacks.                      to perform and take a long time to com-           tronic medical record, Bar Code Medication
                                                    plete. Computer models are programs that          Administration (BCMA) and provider order
Systematic reviews of research offer the            simulate the effects of different treatments      entry, strong pharmacy benefit, Technology
easiest method by utilizing existing studies        on various populations. This method has           Assessment Program (TAP) – and outstand-
and synthesizing them to make additional            been suggested as an alternative or an addi-      ing researchers.
comparisons. Analyses of claims records             tion to clinical trials. Each of these analyti-
offer a more complex and time consuming             cal methods offers advantages and                 References
method by utilizing existing sources of raw         disadvantages in studying comparative             1. Smith S, Heffler S, Freeland M. The Next Decade of
                                                                                                         Health Spending: A New Outlook. The National
data. One advantage of this method is that          effectiveness; these techniques should be
                                                                                                         Health Expenditures Projection Team. Health Affairs
it provides new information to resolve              customized depending on the research                 (Millwood), 1999 Jul-Aug; 18(4):86-95.
questions about treatments at a relatively          question, or combined to answer specific
low cost. One of the main difficulties with         questions.

VA Office of Research & Development, Health Services Research & Development Service                                                                May 2009
FORUM — Translating research into quality health care for Veterans                                                                                 3

                                                                                                      dreds of innovations. CEA is widely used in
                                                                                                      other countries, where it is among the crite-
Response to Commentary
                                                                                                      ria used to make coverage decisions.
Comparative Effectiveness Research
                                                                                                      VHA: The Challenge to Lead
and Beyond                                                                                            in Comparative Effectiveness
Paul G. Barnett, Ph.D., VA HSR&D’s Health Economics Resource Center                                   The Veterans Health Administration (VHA)
                                                                                                      is well positioned to be a U.S. leader in
                                                                                                      applying both comparative effectiveness
Despite great advances in medical knowl-            by U.S. decision makers. This may be be-
                                                                                                      and cost-effectiveness research. VHA is a
edge, the effectiveness of many health              cause they do not understand the uses of
                                                                                                      globally budgeted, national system, with
services is unknown. Comparative effective-         CEA, because they feel that its methods are
                                                                                                      the long-term responsibility for the health
ness research can close this gap and improve        unreliable, or because findings have not
                                                                                                      of a well-defined population. Research is
the quality of U.S. health care. The value of       been relevant to their particular setting or
                                                                                                      integrated with VHA care. VHA utilization
this research is widely appreciated. Effec-         time-horizon.3
                                                                                                      and cost data are the envy of other health
tiveness evaluations are almost universally
                                                                                                      care plans.
employed by public and private health plans          Other reasons why CEA may not be used
to determine what new technologies they             include political opposition from drug and
                                                                                                      Social value judgements about vulnerable
will cover.1                                        device developers, and unwillingness of
                                                                                                      or especially deserving plan members need
                                                    Americans to concede that effective but
                                                                                                      to be incorporated into decisions based on
Comparative effectiveness research may not          expensive treatments cannot be provided
                                                                                                      CEA. This type of review has been impor-
answer all decision makers’ questions, how-         if benefits are modest.
                                                                                                      tant to the acceptance of CEA in other
ever. An effectiveness study can determine
both benefits and adverse effects of an             As Dr. Almenoff points out, new technology
intervention, but this does not reveal              accounts for much of the increase in health
                                                                                                      Veterans are a well-organized constituency
whether the health improvement outweighs            care costs. CEA can help determine if inno-
                                                                                                      that deserves to participate in VHA cover-
the possible harm. Even with clear evidence         vations yield sufficient value to justify their
                                                                                                      age decisions.
that a new test can more effectively detect         cost. CEA methods have been standardized
disease, other evidence is needed to know if        for more than a decade and applied to hun-
early detection confers a net benefit. Data
                                                                                                                                  continued on page 8

from many sources must be linked.
                                                       Recently, FORUM spoke with Al Perry, Director, VA Central California Health Care
Using CEA to Extend                                    System regarding the challenges facing VHA Senior Leadership Teams in the
Comparative Effectiveness
These types of limitations in comparative
                                                       field. Perry described five challenges:
effectiveness research can be overcome by              1. Finding the most effective among constantly evolving treatment techniques,
methods used in Cost-Effectiveness Analy-              programs, equipment, and drugs.
sis (CEA).2
                                                       2. Meeting the challenge of newly eligible Priority Group 8s, and of “victims” of

CEA values health outcomes using a meas-
                                                       the economic downturn.

ure of morbidity adjusted survival called the          3. Delivering health care services to returning OEF/OIF Veterans, particularly
Quality Adjusted Life Year (QALY). This                those with mental health care needs and those living in rural areas.
measure can also be applied to comparative
effectiveness research, to trade off benefits
                                                       4. Delivering increasingly expensive services under tight budget constraints.

against harm. The medical decision model-              5. Addressing ever increasing expectations for measurable quality and out-
ing methods employed in CEA can be used                comes.
in comparative effectiveness research, to
link effectiveness findings to studies of              HSR&D research topics of interest to leadership in the field include: provider be-
long-term health outcomes.                             havior, comparative technology, inpatient vs. outpatient treatment particularly
                                                       for mental health, settings and approaches to women’s health, and solo vs.
Despite its versatility, CEA is not nearly as          team or group treatment.
well regarded as comparative effectiveness

VA Office of Research & Development, Health Services Research & Development Service                                                        May 2009
FORUM — Translating research into quality health care for Veterans                                                                                          4

                                                                                                      gestive of HIV infection (as is usual ED
                                                                                                      practice). We estimated the number of peo-
Research Highlights
                                                                                                      ple who would be identified as HIV-infected
Analysis of the Cost of an HIV Rapid                                                                  through routine rapid testing, the start-up
                                                                                                      and maintenance costs of the rapid test pro-
Testing Initiative                                                                                    gram, and diagnostic and treatment costs
                                                                                                      for HIV-infected patients identified by rapid
                                                                                                      testing. We then compared these costs to
Matthew Bidwell Goetz, M.D., Center of Excellence for the Study of Healthcare
                                                                                                      the expenses incurred by patients identified
Provider Behavior, VA Greater Los Angeles Healthcare System
                                                                                                      as being HIV-infected at later stages of dis-
The benefits of identifying and treating             near-term financial costs of program imple-      ease through routine practice.
asymptomatic Human Immunodeficiency                  mentation.1
Virus (HIV)-infected individuals substan-                                                             Using base case data from a single VA ED,
tially exceed those of early recognition of          Even for programs that reduce costs (i.e.,       we found that a rapid test program that
most medical conditions. Routine HIV test-           are cost saving), the savings are usually over   makes use of ED capacity during non-peak
ing is of particular importance to the VA,           a period of many years and the immediate         hours was not more costly than usual ED
the largest provider of HIV services in the          implementation costs may overshadow              practice. This result is likely due to the high
United States. Nevertheless, in the VA, as in        short-term savings. This temporal financial      costs of care of patients who present with
many other health care systems, 50 percent           mismatch is magnified for programs that are      late stage disease when current practice is
of HIV-infected patients are diagnosed after         cost-effective rather than cost saving. Con-     followed. Given that early detection of HIV
they have developed severe immunological             sequently, both Cost-Effectiveness and           and linkage to treatment is associated with
damage.                                              Business Case Models are necessary to ap-        better health outcomes, and that the rapid
                                                     propriately estimate short-term and long-        test program does not cost more than cur-
Among the deterrents to promoting early              term financial impact.                           rent practice, this budget impact analysis
routine HIV testing is that reliance on stan-                                                         provides support for the implementation of
dard blood tests requires that patients re-          Following this paradigm, we first conducted      HIV rapid testing programs in VA EDs.3
ceive their test results at a later date; this can   a cost-effectiveness analysis of the long-
present a considerable barrier for homeless          term financial and health impacts of nurse-      Conclusion
and transient patients. To address this bar-         based HIV rapid testing as opposed to            Often, long-term cost-effectiveness assess-
rier, QUERI-HIV/Hepatitis has undertaken             physician-ordered traditional blood-based        ments are used to establish the value of an
a series of studies to evaluate the utility of       HIV testing. This evaluation built upon pre-     initiative such as routine HIV testing. How-
same-day, oral fluid-based HIV rapid testing         vious analyses that demonstrated that rou-       ever, even when the long-term value of a
programs. One such study, which was con-             tine blood-based HIV testing is cost-            program is clear, the realities of implemen-
ducted in a primary care clinic setting,             effective on a societal basis at the $50,000/    tation in the near term can create significant
demonstrated increased patient satisfaction          QALY threshold for populations where the         barriers for acceptance. Effective BCM as-
and receipt of test results with nurse-based         prevalence of undiagnosed HIV infection is       sesses the short-term costs and benefits to
offer and performance of HIV rapid tests             greater than 0.05 percent. In analyses that      evaluate the consequences of implementing
as opposed to traditional physician-ordered,         considered the time spent for pre-test coun-     new initiatives.
blood-based HIV testing.                             seling, test performance and post-test coun-
                                                     seling, laboratory supplies, and the care of     References
Economic Impact of HIV Rapid                         persons found to be HIV-infected, we             1. Mauskopf JA, Sullivan SD, Annemans L, et al.
                                                                                                         Principles of Good Practice for Budget Impact
Testing                                              found that compared with the blood-based            Analysis: Report of the ISPOR Task Force on Good
To assess the economic impacts of rapid              testing, the incremental cost of nurse-based        Research Practices - Budget Impact Analysis. Value
testing, we conducted two separate comple-           rapid testing was $10,689/QALY when so-             Health 2007; 10:336-47.
                                                                                                      2. Sanders GD, Anaya H, Asch S et al. Cost Effectiveness
mentary Cost-Effectiveness and Business              cietal benefits were considered.2                   of Rapid HIV Testing with Streamlined Counseling
Case Model (BCM, also referred to as                                                                     2007; Sydney, Australia; July 22-25, 2007.
Budget Impact Analysis) analyses. Whereas            More recently, we developed a BCM to             3. Gidwani R, Goetz MB, Needleman J et al. Develop-
                                                                                                         ment of Business Case Methodology Using VA Data:
cost-effectiveness analyses consider the             compare the financial impact of routinely
                                                                                                         Implications for QUERI Research Projects. VA
long-term (i.e., over a patient’s lifetime) fi-      offering rapid HIV tests during non-peak            HSR&D Annual Meeting 2009; Baltimore, MD.
nancial and health impacts of an interven-           hours in a VA Emergency Department
tion from a health care system or societal           (ED) versus offering diagnostic testing only
perspective, BCM analyses evaluate the               for patients presenting with symptoms sug-

VA Office of Research & Development, Health Services Research & Development Service                                                                May 2009
FORUM — Translating research into quality health care for Veterans                                                                                  5

                                                                                                     In step 3, researchers linked each study
                                                                                                     participant’s utilization and function to
Research Highlights
                                                                                                     the cost matrix to compute individual total
Estimating Future Costs of Prosthetic                                                                annual costs. In step 4, the study’s expert
                                                                                                     panel of VA and DoD rehabilitation
Devices                                                                                              leadership, rehabilitation and prosthetic
                                                                                                     specialists, academic and private practice
                                                                                                     physicians, prosthetists, researchers, and
David K. Blough, Ph.D., University of Washington, Seattle, Washington,
                                                                                                     service members with limb loss made
Sharon Hubbard, M.S., Prosthetics Research Study, Seattle, Washington,
                                                                                                     recommendations on model parameters in
Lynne V. McFarland, Ph.D., and Gayle E. Reiber, M.P.H., Ph.D., both with
VA Puget Sound Health Care System, Seattle, Washington                                               areas where there is no published data. In
                                                                                                     step 5, researchers projected total cumula-
Recently, the Department of Defense (DoD)           those with major limb loss. As such, it is
                                                                                                     tive prosthetic costs for 5-year, 10-year,
issued a Rehabilitation Directive, the goal of      crucial to estimate future costs of prosthetic
                                                                                                     20-year, and lifetime time horizons. We did
which is to return service members with             devices in order to plan appropriately for
                                                                                                     this separately for OEF/OIF service mem-
limb loss from Operation Enduring Free-             effective resource allocation. We conducted
                                                                                                     bers and Vietnam Veterans suffering trau-
dom and Operation Iraqi Freedom (OEF/               a study of prosthetic costs as part of a
                                                                                                     matic limb loss. Type of limb loss was
OIF) to pre-injury function and provide them        larger research project involving service
                                                                                                     categorized as isolated lower, isolated upper,
the option of returning to active duty. To          members with traumatic limb loss from
                                                                                                     bilateral upper, and multiple limb loss. For
meet this goal, the DoD Amputee Patient             Vietnam and OEF/OIF.
                                                                                                     Vietnam and OEF/OIF cohorts, and each
Care Programs and VA Medical Centers
                                                                                                     category of limb loss, we used separate cost-
offer state-of-the-art comprehensive reha-          In step 1 of the study (see figure), re-
                                                                                                     projection models.
bilitation care, including prosthetic care.         searchers conducted a nationwide survey,
                                                    which identified Vietnam and OEF/OIF
                                                                                                     The analysis results in cost distributions for
VA limb distribution practice allows any            service members’ prosthetic history since
                                                                                                     projections over all time horizons and types
Veteran with limb loss to request and/or re-        limb loss and current assistive-device use. In
                                                                                                     of limb loss. Overall, our model indicates
ceive any prosthetic device if deemed med-          step 2, researchers developed a cost matrix
                                                                                                     that for OEF/OIF service members with
ically appropriate, feasible and/or indicated       for all upper and lower limb prosthetic costs
                                                                                                     isolated lower limb loss, 5-year, 10-year, 20-
according to their functional level. Pros-          and assistive devices, and then categorized
                                                                                                     year, and lifetime average per-person costs
thetic care is one component of a compre-           these by level of function using Medicare
hensive rehabilitation care program for             costs as the common metric.                                                   continued on page 8

  Cost Projection Steps, Vietnam and OEF/OIF Service Members
  with Major Traumatic Limb Loss

                                                                                                                              5. Results

                                                                                             4. Markov Models             Projected 5-, 10-,
                                                                3. Current Cost File                                     20-year, and lifetime
                                                                                                   Conflict                prosthetic costs
                                     2. Cost Matrix
     1. National Survey                                                                        Limb loss level
           Inputs                                                    Study ID:
                                    Limb loss level                   Conflict                  Activity level
          Study ID:                 Prosthetic type                 Activity level             Prosthetic cost
           Conflict               Assistive device type        Prosthetic/Assistive type   Transition probabilities
       Limb loss level               Activity level                   Quantity
       Prosthetic type                                                  Usage               Expert panel inputs
           Quantity                  Medicare cost is           Medicare cost each
            Usage                    common metric              Medicare cost total
    Assistive-device types                                      Validated by expert
        Activity level                                              prosthetists

VA Office of Research & Development, Health Services Research & Development Service                                                        May 2009
FORUM — Translating research into quality health care for Veterans                                                                                          6

                                                                                                       justments can be made. VA hospitals show
                                                                                                       moderate differences (e.g. age, income) in
Research Highlights
                                                                                                       the patient population they admit with heart
Readmission for Heart Failure                                                                          failure and such differences are likely to im-
                                                                                                       pact readmission rates.
Paul Heidenreich M.D., M.S., Chronic Heart Failure QUERI, VA Palo Alto
Health Care System                                                                                     Heart Failure Readmissions and
Heart failure is a chronic syndrome associ-                                                            Since heart failure admissions account for
                                                                                                       up to 80 percent of the cost of heart failure
                                                    Readmission as a Measure of
ated with frequent exacerbations often re-
                                                                                                       care, knowing the impact on heart failure
                                                    Health Outcome and Quality of
sulting in hospitalization and death.1 Readmis-
                                                                                                       admissions is important for all cost-effec-
sion for heart failure occurs within 30 days        While a heart failure readmission clearly
following 20 percent of discharges from                                                                tiveness analyses of heart failure interven-
                                                    increases cost, its use as a measure of health
the VA system with similar rates in the                                                                tions. As a general rule, any treatment that
                                                    outcome is less clear. One of the principles
Medicare health care system. The high rate                                                             reduces heart failure hospitalizations (or
                                                    of care coordination is delivering the opti-
of hospitalization has led to cost estimates                                                           mortality) is likely to be cost-effective com-
                                                    mal care in the optimal setting. Occasionally
of over $37 billion for heart failure care in                                                          pared to other accepted health interven-
                                                    this setting is in the hospital, and trying to
the United States for 2009.2                                                                           tions. Many disease management programs
                                                    keep some patients out of the hospital may
                                                                                                       have reduced heart failure readmissions,
                                                    result in inferior care.
Given the high cost and morbidity associ-                                                              though recent trials have had difficulty
ated with heart failure hospitalization,                                                               showing significant reductions, perhaps due
                                                    If readmission is a valid measure of the
recent research has focused on preventing                                                              to the improvement in usual care for heart
                                                    quality of heart failure care, it should satisfy
admissions and readmissions in particular.                                                             failure.
                                                    several criteria. First, a significant fraction
Accordingly, preventing readmissions is             of readmissions should be due to preventa-
now a focus of heart failure studies includ-                                                           Data from VA, non-VA U.S., and non-U.S.
                                                    ble causes. Unfortunately, heart failure as
ing studies related to comparative effective-                                                          countries have demonstrated that as recom-
                                                    the primary diagnosis accounts for only
ness. The rate of heart failure readmission                                                            mended medication use has increased so has
                                                    about a third of readmissions. Half of all
has been discussed as a possible perform-                                                              survival following a hospitalization for heart
                                                    readmissions are due to non-cardiac causes
ance measure by the VA, Joint Commission,                                                              failure. Unfortunately, readmission rates
                                                    (as the principal diagnosis), and the remain-
and Centers for Medicare and Medicaid                                                                  have not similarly improved in the VA and
                                                    der of readmissions (one sixth) is due to
Services. The latter plans to release to the                                                           data from the U.S. National Hospital Dis-
                                                    non-heart failure cardiac causes.
general public risk-adjusted 30-day heart                                                              charge Survey indicate a slight increase in
failure readmission rates for all non-                                                                 hospitalization rates from 1995-2004.
                                                    Second, one should be able to distinguish
government hospitals in summer 2009.                                                                   While a heart failure admission is a clear
                                                    elective from non-elective readmissions.
                                                                                                       contributor to the cost of care, using it as
                                                    Presumably the non-elective admissions are
A heart failure readmission may be defined                                                             an outcome or quality measure is challeng-
                                                    more indicative of quality of care. Patients
in multiple ways. It can be the primary cause                                                          ing. Cost-effectiveness and comparative
                                                    may be readmitted for elective device place-
of admission (coded as a principal diagnosis),                                                         effectiveness studies should not limit their
                                                    ment (e.g. defibrillator or resynchronization
a contributing factor (coded as one of the                                                             outcome assessments to readmission when
                                                    therapy) and the diagnosis may be coded as
secondary diagnoses), or it may be unrelated                                                           evaluating heart failure treatments.
                                                    heart failure.
to heart failure but occurring within a certain
time period following a heart failure dis-          Third, all relevant admissions should be
                                                                                                       1. Hunt SA, Abraham WT, et al. 2009 Focused Update
charge. Using the principal diagnosis criteria,     captured. Often, readmissions for Veterans            Incorporated Into the ACC/AHA 2005 Guidelines for
readmission occurs in 10 percent of patients        are not captured using VA records because             the Diagnosis and Management of Heart Failure in
at 30 days following discharge compared to          many Veterans receive cardiology care for
                                                                                                          Adults. A Report of the American College of Cardiol-
                                                                                                          ogy Foundation/American Heart Association Task
20 percent if one defines heart failure as a        heart failure outside of the VA system. This          Force on Practice Guidelines. Circulation. Mar 26
primary or secondary diagnosis. An admis-           dual use may bias results of comparative ef-          2009.
sion for any cause occurs in approximately          fectiveness and cost-effectiveness studies.        2. Lloyd-Jones D, Adams R, et al. Heart Disease and
                                                                                                          Stroke Statistics – 2009 Update: A Report from the
25 percent of heart failure patients at 30
                                                                                                          American Heart Association Statistics Committee and
days following discharge.                           Finally, variation in case mix should be min-         Stroke Statistics Subcommittee. Circulation
                                                    imal or measurable so that appropriate ad-            2009;119(3):480-6.

VA Office of Research & Development, Health Services Research & Development Service                                                                May 2009
FORUM — Translating research into quality health care for Veterans                                                                                  7

                                                                                                   VA’s Chief Research and Development Of-
Highlights of the 2009 HSR&D                                                                       ficer, Dr. Joel Kupersmith, and HSR&D Di-
                                                                                                   rector, Dr. Seth Eisen, each spoke about
National Meeting                                                                                   current VA research priorities, such as the care
                                                                                                   of complex chronic conditions and post-
“Defining Optimal Care: Balancing Quality,          I Impact of Novel Patient Educational
                                                                                                   deployment health. The keynote address was
Cost, and Patient Preferences” was the              Booklet on Colonoscopy Preparation in
                                                                                                   provided by Nicole Lurie, M.D., M.S.P.H.,
theme of the 27th VA Health Services Re-            Veterans by Brennan Spiegel, M.D.,
                                                                                                   Director of Population Health and Health
search and Development Service (HSR&D)              M.S.H.S., and
                                                                                                   Disparities and Co-Director of the Center
National Meeting held February 11-13, 2009
                                                    I Assessing VA Mental Health Intensive         for Domestic and International Health Se-
in Baltimore. The Center for Clinical Man-
                                                    Case Management: Program Effects on            curity at the RAND Corporation, who spoke
agement Research – HSR&D’s Center of
                                                    Mental Health Services Use by Eric Slade,      about the rapidly changing health care envi-
Excellence in Ann Arbor, Mich. served as
                                                    Ph.D.                                          ronment. Dr. Lurie’s thoughts on the topic
this year’s meeting host. More than 660
                                                                                                   were of particular interest given her recent
policymakers, clinicians, and researchers
                                                    Other meeting highlights included an           role as a member of the Obama Transition
attended the meeting where 82 papers, 18
                                                    address by then VA Under Secretary for         Project’s Agency Review Working Group,
workshops, and 125 posters were presented
                                                    Health Michael Kussman, M.D., M.S.,            for which she assessed the U.S. Department
on vital health care issues, such as chronic
                                                    MACP, who also presented two of VHA’s          of Health and Human Services.
illness, vulnerable populations, mental health,
economic analysis, and long-term care.              highest honors. H. Gilbert Welch, M.D.,
                                                    M.P.H. received the Under Secretary’s          Meeting abstracts are available at www. hsrd.
                                                    Award for Outstanding Achievement in           research.va.gov/meetings/2009/abstracts.
In addition to the exceptional peer-reviewed
                                                    Health Services Research. Part of the          cfm. Slide presentations are available on the
research presented over the course of the
                                                    White River Junction VA Medical Center         VA Intranet only at vaww.hsrd.research.va.
meeting, the meeting offered a day devoted
                                                    in Vermont, Dr. Welch has made significant     gov/meetings/2009/presentations.cfm
to HSR&D’s Career Development Program.
One of HSR&D’s greatest strengths is the            contributions in the areas of technology
high caliber of its investigators. Supporting       assessment, health policy, and understand-      Several new Special Interest Groups (SIG)
the development of investigators in the             ing the benefits and harms of early diagno-     have formed within HSR&D. See informa-

early, mid- and advanced stages of their ca-        sis. The other honor was presented to Dr.
                                                                                                    tion about joining or starting a new SIG at

reers is a high priority. The meeting also of-      Shirley Meehan (see box).

fered several special interest group sessions
and breakfast sessions on topics ranging
from ways to improve health care for Veter-
ans living in rural settings, to strategies for        Meehan Receives VA’s Exemplary Service Award
improving VA/DoD research collabora-                                        Dr. Kussman presented the highest honor bestowed by the Of-
tions, to genomics.                                                         fice of the Under Secretary – VA’s Exemplary Service Award –
                                                                            to Shirley Meehan, M.B.A., Ph.D., HSR&D Deputy Director. Dr.
A special plenary paper session highlighted                                 Meehan received the award at the 2009 HSR&D National Meeting.
the five top scoring abstracts submitted to
the meeting. The topics of these five pre-                                During her 38-year tenure with VA, Dr. Meehan contributed
sentations were as follows:                                               in many ways to improving the health and health care of
I A Cost-Benefit Analysis of Higher Med-
                                                       Veterans. She began working within research in the 1970s, helping to build the
ication Copayments in Veterans with Schiz-
                                                       infrastructure of the health services research program. Most of us know her best
ophrenia by John Zeber, Ph.D.,
                                                       as Deputy Director of HSR&D, a position she has held since 1992. In the Deputy
                                                       role, she helped to enhance the HSR&D program by strengthening the merit
I Case/Self Management in COPD: A                      review process, contributing to the development of the HSR&D Centers of
Randomized Trial by Kathryn Rice, M.D.,                Excellence, shaping the Career Development Award Program and more recently,
I AUDIT-C Alcohol Misuse Screening
                                                       helping construct the Evidence Synthesis Program. In addition, she helped shape
and Post-operative Complications: A Co-
                                                       the HSR&D research portfolios and guided the hiring and training of the excel-
hort Study of Men Undergoing Major Sur-
                                                       lent Scientific Program Managers who currently oversee them. Dr. Meehan
gery in VA by Katharine Bradley, M.D.,
                                                       retired from VA on May 1, 2009.

VA Office of Research & Development, Health Services Research & Development Service                                                      May 2009
FORUM — Translating research into quality health care for Veterans                                                                                                              8

Response to Commentary                                      Research Highlights
continued from page 3                                       continued from page 5

Researchers must do a better job of learn-                  are $229,000, $474,000, $856,000 and $1.5
ing the needs of health care decision mak-                  million, respectively. The corresponding costs            Geraldine McGlynn, Editor-in-Chief

ers. (For an example, see the concerns of                   for the Vietnam group were estimated to be
                                                                                                                      Margaret Trinity, E ditor

medical center director Alan Perry in the                   $82,251, $167,848, $281,234, and $342,716,               Editorial Board
side bar). We must clearly articulate our                   respectively. The mean costs for the OEF/OIF             David Atkins, M.D., M.P.H.,       Seth A. Eisen, M.D., M.Sc.,

methods. Our studies must be more rele-                     group are 2.8 fold to 6.2 fold higher than the
                                                                                                                     Acting Deputy Director of         Director, HSR&D
                                                                                                                     HSR&D and QUERI Director          VA Central Office, Wash-

vant and timely. We can shorten our re-                     corresponding costs for the Vietnam group.
                                                                                                                     VA Central Office, Washing-       ington, DC

sponse time by developing models of care                    This reflects higher costs for the more tech-
                                                                                                                     ton DC
                                                                                                                                                       Joseph Francis, M.D., M.P.H.,

for major diseases in anticipation of future                nologically advanced prostheses, use of
                                                                                                                     Peter L. Almenoff, M.D.,          Acting Chief Quality and

coverage decisions.                                         multiple artificial limbs, and fewer service
                                                                                                                     FCCP, Assistant Deputy            Performance Officer, VA Cen-
                                                                                                                     Under Secretary for Health        tral Office, Washington DC

                                                            members abandoning prosthetic devices.
                                                                                                                     for Quality and Safety, VA
                                                                                                                     Central Office, Washington        Rodney A. Hayward, M.D.,

Every household understands that resources                  The standard deviations of costs steadily in-
                                                                                                                     DC                                Co-Director, VA HSR&D

are limited and that choices must trade off                 crease as the length of the projected time
                                                                                                                                                       Center of Excellence,
                                                                                                                     Cynthia Caroselli, Ph.D., R.N.,   Ann Arbor, MI

value against cost. Comparative effective-                  horizon increases for both groups and all
                                                                                                                     Associate Director for Patient
                                                                                                                     Services & Chief Nurse            Alan S. Perry, M.H.A.,

ness is just the first step on a path to greater            types of limb loss, thus estimating costs
                                                                                                                     Executive, VA New York            FACHE, Director, VA

efficiency. Cost-effectiveness analysis can                 over longer periods has greater uncertainty.
                                                                                                                     Harbor Health Care System,        Central California Health
                                                                                                                     New York, NY                      Care System, Fresno, CA

help us get the best possible outcomes from
the available health care budget.                           Based on our findings we recommend a uni-
                                                                                                                     Martin P. Charns, D.B.A.,         Frances Weaver, Ph.D.,
                                                                                                                     Director, VA HSR&D Center         Director, VA HSR&D Cen-

                                                            form standard of rehabilitation and pros-
                                                                                                                     of Excellence, Boston, MA         ter of Excellence, Hines, IL

References                                                  thetic care for service members with limb              and satisfaction of these service members.
1. Garber, AM. Evidence-based Coverage Policy.              loss cared for by VA directly or through VA            The results of this study will assist VA clini-
   Health Affairs (Millwood), 2001; 20(5): p. 62-82.
2. Russell, LB. The Methodologic Partnership of
                                                            contracts. A uniform standard for coverage             cians and decision makers in planning for
   Effectiveness Reviews and Cost-effectiveness Analysis.   of prosthetic and assistive devices as part            future care of service members with limb loss.
   American Journal of Preventive Medicine, 2001; 20        of their overall rehabilitation care will assist       Findings from the larger study include four
   (3 Suppl): p. 10-2.
                                                            veterans with major traumatic limb loss.               editorials, 10 manuscripts and the expert
3. Neumann, PJ. Why Don’t Americans Use Cost-
   effectiveness Analysis? American Journal of Managed                                                             panel’s clinical and research recommenda-
   Care, 2004; 10(5): p. 308-12.                            The study provided VA clinicians and policy            tions for care of service members with limb
4. Gold, MR, Sofaer S, and Siegelberg T. Medicare and       makers with information on the health, com-            loss. Complete study findings are slated for a
   Cost-effectiveness Analysis: Time to Ask the Tax-
   payers. Health Affairs (Millwood), 2007; 26(5):          bat injuries, function, quality of life, prosthetic-   special issue of the Journal of Rehabilitation
   p. 1399-406.                                             device utilization, replacement, abandonment,          Research and Development later this year.

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