Evidence-Based Clinical Practice Guidelines in the Veterans Health Administration

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

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

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

4. VA/DoD Executive Council VA/DoD EBP Working Group Veteran’s Affairs AMEDD AFMOA BUMED Quality Management Joe Francis, MD, VA Office of Quality & Performance COL Doreen Lounsbery, MD, Office of Evidence-Based Practice CAPT Neal Naito MC, Navy Clinical Plans & Management Col Erika Barger, MC, Air Force Medical Operations Agency

5. Goals of VA/DoD Evidence-based Guidelines • Summarize evidence and recommendations that can form the basis of clinical policy and delivery system design • Create tools that assist clinicians and managers in implementing evidence into practice • Guide local quality improvement efforts • Reduce waste & inappropriate variation • Enhance population health

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

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

8. What’s Different About the VA/DoD? • Integrated Health Systems • Mission-driven culture • Strong emphasis on primary care • Wide-spread electronic health record • Ten year experience with a robust set of performance metrics

9. Decision Support Performance Measures Appropriateness Measures Clinical Guidelines Evidence Clinical Processes & Systems Formulary Clinical Reminders Evidence as the Basisfor Clinical Policy

10. What’s Improved • Greater use of systematic reviews • More explicit presentations of evidence • More explicit designation of when evidence is inadequate • ? Multidisciplinary representation

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

13. Problems in Guideline Presentation • Is goal to write a textbook or improve care? • Little distinction between recommendations with widely varying health impact • Not written with translation to tools in mind • Computerized decision support • Performance measures • Coverage decisions • Limited attention to costs, feasibility, or patient values • Often contribute to misguided attempts to dichotomize quality of care: good vs. bad

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

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