Evidence-Based Evidence-Based Clinical Practice GuidelinesClinical Practice Guidelines

in the Veterans Health in the Veterans Health AdministrationAdministration

David Atkins, MD, MPHDavid Atkins, MD, MPHHealth Services Research and DevelopmentHealth Services Research and Development

Quality Enhancement Research InitiativeQuality Enhancement Research InitiativeDept. of Veterans AffairsDept. of Veterans Affairs

ObjectivesObjectives

• Briefly review the joint VA/DOD guideline Briefly review the joint VA/DOD guideline development effortdevelopment effort

• Describe the role of guidelines in system-wide Describe the role of guidelines in system-wide quality improvement quality improvement

• Reflect on future challenges and implications Reflect on future challenges and implications for guideline developmentfor guideline development– Guideline development processGuideline development process– Guideline productsGuideline products

Guidelines in The VA Health SystemGuidelines in The VA Health System

• VA is a user and developer of VA is a user and developer of guidelinesguidelines

• Integrated health system serving 5 million Integrated health system serving 5 million VeteransVeterans– 200,000 employees200,000 employees

• Collaborates with Dept. of Defense to Collaborates with Dept. of Defense to develop common guidelines for active develop common guidelines for active duty and retired service membersduty and retired service members

AMEDDAMEDD

Quality Quality ManagementManagement

COL Doreen COL Doreen Lounsbery, Lounsbery, MD, Office of MD, Office of

Evidence-Based Evidence-Based PracticePractice

BUMEDBUMED

CAPT Neal Naito CAPT Neal Naito MC, Navy Clinical MC, Navy Clinical

Plans & Plans & ManagementManagement

Veteran’s Veteran’s AffairsAffairs

Joe Francis, MD,Joe Francis, MD, VAVA

Office of QualityOffice of Quality& Performance& Performance

AFMOAAFMOA

Col Erika Barger, Col Erika Barger, MC, Air Force MC, Air Force

Medical Medical Operations Operations

AgencyAgency

VA/DoD Executive CouncilVA/DoD Executive Council

VA/DoD EBP Working GroupVA/DoD EBP Working Group

Goals of VA/DoD Goals of VA/DoD Evidence-based GuidelinesEvidence-based Guidelines

• Summarize evidence and recommendations Summarize evidence and recommendations that can form the basis of clinical policy and that can form the basis of clinical policy and delivery system design delivery system design

• Create tools that assist clinicians and Create tools that assist clinicians and managers in implementing evidence into managers in implementing evidence into practicepractice

• Guide local quality improvement effortsGuide local quality improvement efforts• Reduce waste & inappropriate variationReduce waste & inappropriate variation• Enhance population healthEnhance population health

Why a VA/DoD Why a VA/DoD Guideline Development Process?Guideline Development Process?

• Allows tailoring to the needs of the current or former Allows tailoring to the needs of the current or former service memberservice member– may assist seamless transitionmay assist seamless transition

• Provides check on Industry & Professional Group biasesProvides check on Industry & Professional Group biases• Strong adoption of evidentiary standardsStrong adoption of evidentiary standards• Focus on primary careFocus on primary care• Use of algorithms and other tools to assist providersUse of algorithms and other tools to assist providers• Enhances ability to drive clinical policy Enhances ability to drive clinical policy

VA/DoD CPGs Available for UseVA/DoD CPGs Available for Use

• AsthmaAsthma• Amputation RehabilitationAmputation Rehabilitation• Chronic Heart FailureChronic Heart Failure• Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary

DiseaseDisease• Diabetes MellitusDiabetes Mellitus• DyslipidemiaDyslipidemia• Dysuria in WomenDysuria in Women• Erectile DysfunctionErectile Dysfunction• GERDGERD• HypertensionHypertension• Ischemic Heart DiseaseIschemic Heart Disease• Kidney DiseaseKidney Disease• Low Back PainLow Back Pain

• Major Depressive DisorderMajor Depressive Disorder• Management of Tobacco UseManagement of Tobacco Use• Medically Unexplained Symptoms: Medically Unexplained Symptoms:

Chronic Pain & FatigueChronic Pain & Fatigue• Opioid Therapy for Chronic PainOpioid Therapy for Chronic Pain• ObesityObesity• Post-Operative PainPost-Operative Pain• Post-Deployment HealthPost-Deployment Health

– Screening Health ExamScreening Health Exam• Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder• PsychosisPsychosis• Stroke RehabilitationStroke Rehabilitation• Substance Use DisorderSubstance Use Disorder• Uncomplicated PregnancyUncomplicated Pregnancy

Posted to Posted to www.Guideline.govwww.Guideline.gov (National Guideline Clearing House): (National Guideline Clearing House):

also also Biological, Chemical, and Radiation-Induced Illnesses Pocket CardsBiological, Chemical, and Radiation-Induced Illnesses Pocket Cards

What’s Different About the What’s Different About the VA/DoD? VA/DoD?

• Integrated Health SystemsIntegrated Health Systems

• Mission-driven cultureMission-driven culture

• Strong emphasis on primary careStrong emphasis on primary care

• Wide-spread electronic health recordWide-spread electronic health record

• Ten year experience with a robust set of Ten year experience with a robust set of performance metricsperformance metrics

Evidence as the BasisEvidence as the Basisfor Clinical Policyfor Clinical Policy

ClinicalGuidelines

Evidence

FormularyClinical

Processes & Systems

AppropriatenessMeasures

DecisionSupport

PerformanceMeasures

ClinicalReminders

What’s ImprovedWhat’s Improved

• Greater use of systematic reviewsGreater use of systematic reviews

• More explicit presentations of evidenceMore explicit presentations of evidence

• More explicit designation of when More explicit designation of when evidence is inadequateevidence is inadequate

• ? Multidisciplinary representation? Multidisciplinary representation

Problems with Guideline Problems with Guideline Development DevelopmentDevelopment Development

• Process still too inefficientProcess still too inefficient– Effort not always matched to value; redundancyEffort not always matched to value; redundancy

• Conflict of interest persistsConflict of interest persists– Not solved by disclosure aloneNot solved by disclosure alone

• Too much effort on less important areasToo much effort on less important areas• Too little attention to harms, tradeoffsToo little attention to harms, tradeoffs• Panels often don’t reflect the targets audience Panels often don’t reflect the targets audience

of guidelinesof guidelines– Primary care under-representedPrimary care under-represented– Patient representation challengingPatient representation challenging

Problems in Guideline Problems in Guideline PresentationPresentation

• Is goal to write a textbook or improve care?Is goal to write a textbook or improve care?• Little distinction between recommendations with Little distinction between recommendations with

widely varying health impactwidely varying health impact• Not written with translation to tools in mindNot written with translation to tools in mind

– Computerized decision supportComputerized decision support– Performance measuresPerformance measures– Coverage decisionsCoverage decisions

• Limited attention to costs, feasibility, or patient Limited attention to costs, feasibility, or patient valuesvalues

• Often contribute to misguided attempts to Often contribute to misguided attempts to dichotomize quality of care: good vs. baddichotomize quality of care: good vs. bad

Future ChallengesFuture Challenges

• Tensions between practical guidance vs. Tensions between practical guidance vs. individualized careindividualized care– Benefits of many recommendations depend critically on Benefits of many recommendations depend critically on

individual characteristics (e.g. lipids, osteoporosis)individual characteristics (e.g. lipids, osteoporosis)– Role of age, co-morbidity, poly-pharmacyRole of age, co-morbidity, poly-pharmacy

• How can guidelines better promote progress How can guidelines better promote progress towards goal vs. arbitrary goal?towards goal vs. arbitrary goal?

• Recognizing system factors and implementationRecognizing system factors and implementation• Are there practical ways to incorporate patient Are there practical ways to incorporate patient

preferences? preferences? • Coordination across different groupsCoordination across different groups

RecommendationsRecommendations

• Strong policies on conflict of interestStrong policies on conflict of interest• Open peer reviewOpen peer review• Reduce specialty dominance in developing Reduce specialty dominance in developing

guidelines aimed at primary careguidelines aimed at primary care• Address tradeoffs in recommendationsAddress tradeoffs in recommendations

– Preferences, costs, feasibilityPreferences, costs, feasibility

• Consider system and implementation factorsConsider system and implementation factors– Specific language to identify target population and Specific language to identify target population and

actionsactions

• Avoid black/white definitions of “successAvoid black/white definitions of “success””