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FORUM 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 include: 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 Research 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 countries.4 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 Cost-Effectiveness 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- Care 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 References 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). www.hsrd.research.va.gov/for_researchers/sig/ 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. M.P.H., VA Office of Research & Development, Health Services Research & Development Service May 2009 FORUM — Translating research into quality health care for Veterans 8 FORUM 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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