Research Within a Learning Healthcare System: Lessons from the VA - - PowerPoint PPT Presentation

Research Within a Learning Healthcare System: Lessons from the VA

David Atkins, MD, MPH Director, Health Services Research & Development Office of Research & Development Veterans Health Administration | Department of Veterans Affairs

The Nation’s Largest Integrated Health Care System

• In FY 2018, more than 9 million

Veterans were enrolled in VHA

• VA provided care at 1,250

health care facilities, including: – 172 VA medical centers – 1,069 outpatient facilities

• f varying complexity

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Unique Advantages of VA for HSR

• Dedicated research appropriation for research

– $ 722 Million in 2019; Can study T1-T4 translation – $20 million for QUERI program to implement research

• 20+ years of EHR data in national corporate data warehouse
• Integrated care system with social, educational, housing and

disability services – Commitment to caregivers

• Patients committed to helping fellow Veterans

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Need to Distinguish 3 Distinct Questions

• Knowledge Questions – WHAT should we do?

– How should we taper opioids in Veterans taking high- dose therapy?

• Implementation Questions – HOW should we do it?

– What is best way to train and promote delivery of buprenorphine for patients with opioid dependence?

• Execution Questions – HOW can we promote consistent

high-quality care? – How do we improve poor-performing sites for substance use disorder?

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PROBLEM: Too Little of our Research Achieves “Liftoff” (Gets Into Widespread Practice)

• Majority of successful

interventions never get adopted at new sites – Many don’t even get sustained at original site

• Not aligned with top

system priorities

• Researchers often don’t

understand “value proposition” of customer

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Reasons Your Research Might Not Make A Difference

• It takes too long
• Your incentives aren’t aligned with

those of leaders

• You haven’t planned for

implementation at the beginning

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4 Possible Solutions

• New funding mechanisms
• New models for research:

health system partnerships

• New incentives for impact
• Enhanced attention to

implementation

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Why Engage Veterans in VA Research?

• Engagement initiative began in 2015, informed by work of PCORI
• Ensure we ask useful, meaningful research questions that can

improve VA health services

• Improve the quality and relevance of data collection instruments
• Strengthen understanding of our data and the population(s) we

hope to help

• Speed dissemination and uptake of innovations to Veterans and

those who care for them

Levels of Engagement in Research

Participate Consult Involve Collaborate Lead/ Co-Lead

Veteran’s Role

To act as a participant in a research study To provide feedback

• r input on specific

research activities To work directly with a research team throughout a study Partner with researchers on all aspects of a research study Leadership role with decision-making authority on studies

Researcher’s Role

To conduct research in a respectful, ethical manner Veteran(s) asked for input on specific aspects of a research study On-going engagement of Veteran(s) throughout a research study Research teams expanded to include Veterans; provide training as needed Shared leadership and decision- making

Examples

Quantitative, qualitative, mixed methods research Meeting with existing

• r ad hoc groups;

priority setting activities Standing group dedicated to providing input on studies Veteran(s) join research team and act as team member Veterans are research partners or co-investigators

Engagement Meetings

Clockwise from top: Houston, Iowa City, Denver VAMCs

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What are we still learning ?

• Including different perspectives requires a culture shift
• Need new ways to measure impact of Veteran Engagement in

Research

• Need to navigate administrative barriers to training and

compensating Veterans who contribute

• Exploring how to engage Veterans more fully as co-investigators,

reviewers

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Observations on the PCORI Projects

• Caregivers are a critical focus for research and

delivery system

• Engaging Veterans in PTSD research is critical

–Adherence to proven treatments is poor –Recruitment into research is challenging

• Comparative effectiveness research using CDW

–Not able to conduct trials on all treatments

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Conclusions

• Research is critical to a Learning Healthcare System but needs to

evolve to meet the needs of decision makers

• Engagement of stakeholders is critical to that evolution.
• Need to learn from real-world data and natural experiments
• Need to plan for implementation at beginning of any intervention

study – understand perspectives of patients and clinicians

• Relationships (bi-directional) are more important than evidence.

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Why Can It Be Hard for Research to Get Traction in a Large Learning Healthcare System

• Heterogeneous clinical environments
• Dispersed decision making
• Management silos
• Politics reactive decision making
• Need to identify where leaders are willing to act on new or

better information – “decisional equipoise”

• Requires ongoing engagement with all stakeholders

– Patients, clinicians, and leadership

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Past and On-going Veteran Engagement activities in VA Research

Veteran Engagement Workgroup Veteran Engagement Tool kit (SERVE) Jam sessions on Engagement Cyberseminar series

Research Center Level Engagement activities (e.g. Veteran Community Advisory Board, COIN Steering Committee) Individual VA research projects that engage Veterans and VSOs (planning, implementation, & dissemination)

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3 Limitations of Our Research Structure

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