ESP Reports in Progress
The following reports are under development at one of the four ESP sites. If you would like to provide comments about the topic under development, serve as a peer reviewer for the draft report, or know the timeline for completion, please contact the ESP Coordinating Center.
- Family Involved Psychosocial Treatments for Adult Physical Health Conditions
- Advanced Wound Care Products for Wounds Due to Venous Insufficiency, Arterial Insufficiency, or Diabetes
- Mobile Applications for Non-professional Caregivers
- Screening for Post Traumatic Stress Disorder (PTSD): A Systematic Review
- The Effects of Health Plan-sponsored Fitness Center Benefits on Physical Activity
- Group Visits Focusing on Education for the Management of Chronic Conditions in Adults
- Evidence-based guidance for developing shared medical appointments
- The Effects of Family Interventions on Patient Outcomes
- Treatment of Anemia in Patients with Heart Disease
- Research Integrity Literature Synthesis
- My HealtheVet (MHV)
Family Involved Psychosocial Treatments for Adult Physical Health Conditions
Background
Recent legislation (110-387 and 1963) expanded VA authority to provide enhanced services in connection with Service Connected and Non-Service Connected injuries and illnesses. This report will systematically review the evidence on the effect of family/caregiver interventions on outcomes for patients with physical health conditions.
Key Questions
KQ1: What are the benefits of family and caregiver psychosocial interventions for adult patients with common physical health conditions? a. What are the harms of these interventions? b. Do these benefits/harms vary by condition, patient functional status, or outcome?
KQ2: What are the comparative benefits of family and caregiver oriented psychosocial interventions versus patient directed or alternative family oriented interventions in improving outcomes for adult patients with physical health conditions [i.e., how do family oriented interventions compare to (a) any patient-oriented psychosocial intervention or (b) any alternative family oriented intervention]? a. What are the harms of these interventions? b. Do these benefits/harms vary by condition, patient functional status, or outcome?
PICOTS
Population: Adult patients with condition of interest and their family members. The conditions of interest for this report are: cancer, cardiovascular, diabetes/kidney disease, HIV/AIDS, memory impairment, and neurological and musculoskeletal. These conditions were chosen based on their high prevalence and health impact in the VA population.
Intervention: Family-oriented care, including counseling, education, or social support (emotional, instrumental, informational support; companionship). The patient is not required to be present for the intervention.
Comparators: KQ1: No treatment or usual care that involves no additional patient or family directed treatment beyond that usually provided to patients. KQ2: An alternative active treatment directed at: 1) patients (e.g., an additional active patient intervention; 2) families (e.g., another family/couple-oriented intervention)
Outcomes: Patient (not care giver) centered outcomes (e.g., quality of life, hospitalizations institutionalization, instrumental and other activities of daily living, problem behavior, and symptom control/management). Results will be stratified by outcome, primary condition/problem of interest and functional status/severity of condition (e.g., cancer stage, need for ADL assistance). Adverse effects will also be reported.
Timing: Immediate post-intervention, long-term (>6 months).
Setting: Information on where participants were recruited and where participants received treatment will be extracted.
General Search Strategy
We will search MEDLINE and PsycINFO for randomized controlled trials and systematic reviews published in English Language from 1980 to the present.
Advanced Wound Care Products for Wounds Due to Venous Insufficiency, Arterial Insufficiency, or Diabetes
Background and Objectives of Review
The purpose of this review is to generate an evidence base for an algorithm on advanced wound care products. The algorithm is expected to bring consistency to the process of approving expensive products and technologies. This approach should allow for best use of VA resources and provide the best care for veterans.
Key Questions
For wounds caused by a.) venous insufficiency, b.) arterial insufficiency, and c.) diabetes:
1. What is the efficacy of advanced wound care products and technologies?
2. Is the efficacy of advanced wound care technologies and products dependent on ancillary therapies?
3. What are the harms/adverse events associated with advanced wound care products and technologies?
4. Does the efficacy of advanced wound care technologies and products differ according to: patient characteristics, comorbid conditions (e.g., diabetes, obesity, smoking, edema), treatment compliance, or activity level?
PICOTS
Population: Adults with lower extremity wounds associated with venous insufficiency, arterial insufficiency, or diabetes requiring advanced wound care products or technologies
Intervention: Advanced wound care products including platelet derived wound healing products, platelet rich plasma, collagen based wound care products, biological skin equivalents, biological dressings, topical oxygen, hyperbaric oxygen, wound vacuum systems, electromagnetic systems, silver-based topical agents and silver-impregnated dressings
Comparator: Standard care or another advanced wound care product Primary Outcomes: Percent of completely closed/healed wounds, time to complete closure, global assessment, return to daily activities
Secondary Outcomes: Recurrence, infection, amputation or revascularization, pain, hospitalization, home care required, quality of life, withdrawals due to adverse events, all-cause mortality, allergic reactions to treatment,
Timing: Post-treatment, short-term (3 month post-treatment), long-term (9 or 12 month post-treatment), and final (if greater than 12 months) follow-up
Setting: Inpatient or outpatient care
General Search Strategy
MEDLINE will be searched for clinical trials, systematic reviews, and cost-effectiveness studies published in English from 1995 to the present. We will also search the Cochrane Database of Systematic Reviews and hand-search reference lists of relevant systematic reviews and primary studies.
Mobile Applications for Non-professional Caregivers
Background/Objective of Review:
Healthcare technology advocates have long heralded the benefits of computer-based delivery of healthcare information, education, and applications; however, desktop computers (along with the requisite online connection and/or DVD/CD based software) were often under-utilized by healthcare consumers likely due to prohibitive costs, their fixed location, and unintuitive user-interfaces. Recently, applications intended to promote health are increasingly available on the more portable, less expensive, "small screen" devices such as smartphones, personal digital assistants (PDAs) and tablet computers. A growing body of literature examines the patient-care benefits of mobile technologies, including several systematic reviews examining their use in specific chronic disease populations such as obesity, elderly, diabetics, and tobacco-smokers. However, less is known about the benefits of mobile technologies to the non-professional caregivers of patients with these and other chronic illnesses.
Non-professional caregivers are typically not members of a licensed profession such as nursing, medicine, social work or psychology; instead, they are often the family-members or friends of patients with chronic illnesses who either volunteer or work for small wages in order to coordinate the needs of the patient. Caregiver tasks range from the menial (meal preparation, transportation to appointment) to the sophisticated (transfer assistance, healthcare coordination, medication dispensing) and often require non-traditional work hours. Given the responsibility for this diversity of tasks, and the ever-increasing reliance upon them by the healthcare system, caregivers themselves face impacts on their own quality of life, physical and mental well-being, and ability to manage their own healthcare needs. These impacts have been shown to be more frequent and severe for the caregivers of patients with "high need" illnesses, such as dementia, neurologic disorders, and paralysis.
The Department of Veterans Affairs recognizes the essential contribution that non-professional caregivers provide and is currently faced with increasing numbers of veterans who require the assistance of these caregivers due to traumatic brain injuries (TBI) and/or debilitating post-traumatic-stress disorder (PTSD). The objective of this evidence review is to evaluate benefits of mobile technology-based applications in supporting the needs of non-professional caregivers.
To address this objective we will answer the key questions listed under "2. Key Questions, including PICOTS" below.
Key Questions, including PICOTS
Key Question 1. How does the use of consumer health information technologies (CHIT) by non-professional caregivers of adult patients with chronic illnesses or disability, or by such patients who rely on a non-professional caregiver, affect the following outcomes:
Key Question 2. What are the major gaps in the consumer health information technology literature serving non-professional caregivers of adult patients with regards to technology development, availability, and/or evaluation?
Key Question 3. What lessons can be learned from studies evaluating consumer health information technologies (CHIT) that specifically target the parents/caregivers of children?
Contingency-based Key Question 4 (if prior searches reveal scant literature on the above key questions). How does the use of telephony, interactive-voice-response, or telehealth interventions by non-professional caregivers of patients with chronic illnesses or disability, or by such patients who rely on a non-professional caregiver, affect the following outcomes:
Contingency-based Key Question 5 (if prior searches reveal scant literature on the above key questions). What promising non-CHIT caregiver interventions might be adaptable as a CHIT intervention for non-professional caregivers of adults with chronic illnesses?
PICOTS:
Population: Non-professional, non-robot caregivers of adult patients with chronic illnesses, and/or parents of children with healthcare needs.
Intervention: Self-directed mobile applications for use on smart phones, personal digital assistants (PDAs) and tablet computers, including: interactive or individually tailored web-based interventions, decision aids, and risk assessment software; chat and online support groups; secure messaging; or other portable or home-based information tools whose purpose is to facilitate communication, coordination, or education in order to support the emotional, spiritual, organizational, management, and healthcare needs of non-professional caregivers of patients with chronic illnesses or health risk factors. Telephony, interactive-voice-response, and telehealth will also be evaluated if the evaluation of previously mentioned interventions does not yield sufficient results. We are excluding fixed home-monitoring technologies such as smart-homes, vitals-monitoring, GPS and other location-monitoring, and monitoring for patient falls.
There are currently no exclusions as we anticipate only minimal overlap with VA Los Angeles's My Health-e Vet work. Control: Usual care (use of paper forms and educational materials, in-person visits).
Outcomes:
Timing: No restrictions.
Setting: Outpatient (home, assisted living, adult foster care), excluding skilled nursing facilities.
General Search Strategy
We will search PubMed, AMIA proceedings, IEEE Xplore, PsychINFO, CINAHL, and Cochrane Databases using terms for non-professional caregivers and mobile applications (including but not limited to terms for handheld/tablet computers, wireless/mobile technology, iPad, cellular/mobile/android/smart phone, m-health, sms, text messaging, and informatics application).
Screening for Post Traumatic Stress Disorder (PTSD): A Systematic Review
Background and Objectives of Review
Post traumatic stress disorder (PTSD) is the emotional disorder most frequently associated with combat and other potentially traumatic experiences that may occur during the course of military service. The purpose of this review is to identify the screening tools used to detect PTSD in veterans and active duty personnel. The report will focus on psychometric properties of the different screening tools and their administration with an emphasis on how those characteristics may vary based on age, gender, race/ethnicity, substance abuse status, or presence of TBI in the population.
Key Questions, including PICOTS
PICOTS
Population: United States Veterans or active duty personnel
Intervention: Screening methods for PTSD including self-report, interview and multi-stage screening strategies.
Comparator: Structured clinical interviews for PTSD (CAPS), or other "gold standard" in-depth clinical interviews for PTSD.
Outcomes: Diagnostic accuracy (e.g., sensitivity, specificity), implementability (e.g., resources needed for administration/ease of administration).
Timing: Any
Setting: Outpatient or non-clinical active duty
General Search Strategy
MEDLINE and the PILOTS database (from the National Center for PTSD) will be searched for studies published in English from 1981 to the present. We will also focus the search on veterans or military personnel.
The Effects of Health Plan-sponsored Fitness Center Benefits on Physical Activity
Background and Objectives of Review
Regular physical activity has many positive health benefits including better chronic disease management. Moreover, physical activity can lower health care costs. However, the majority of American do not get adequate levels of physical activity. There are multiple, individual, community, and policy barriers that influence physical inactivity. Some studies have showed that health plan-sponsored community-based exercise programs increase levels of physical activity and can reduce health care costs. Therefore, we plan a synthesis of the current literature to assess the impact of health plan benefits or policies that promote access to health clubs on physical activity levels, health outcomes, overall health care costs and health care utilization to inform future VHA policy changes.
Key Questions and PICOTS
The key questions we will address are the following:
KQ1. What are the effects of policy/benefits packages that include vouchers, rebates, premium reductions, etc. to encourage physical activity through fitness center memberships on: participation rates among members, health outcomes (e.g., pain control, weight loss maintenance, etc.), health care costs and utilization?
KQ2. Do the outcomes listed in KQ 1a and 1b differ based of policy/benefits package characteristics (premium vs. lump sum) , or participant characteristics such as gender, age, comorbidity status, urban/rural status, or veteran status?
KQ3. Does providing access to fitness center memberships confer additional benefits (e.g., satisfaction with health plan, retention of members, general well-being) to individuals compared to those without access to fitness center memberships? Do the answers to this question differ based on health package or participant characteristics (listed above)?
General Search Strategy
We plan to conduct a review of the literature by systematically searching, reviewing, and analyzing the empirical evidence as it pertains to the research questions. We plan comprehensive searches of PubMed, EMBASE, Cochrane, SportDiscus and clinicaltrials.gov. Inclusion criteria will be the following: study designs that include only original data from prospective and retrospective observational studies with comparator (sample size ? 100 subjects) or randomized trials (all sample sizes); sample population, adults >18 years of age; setting, public or private health plans ; intervention or exposure must meet the following definition: health plan-sponsored strategies (e.g., vouchers, rebates, premium reductions, etc.) to encourage physical activity through fitness center memberships. (We will exclude studies that examine hospital-based rehabilitation facilities); comparator, usual care or other health plan-sponsored strategy to encourage physical activity through fitness center memberships; study reports on at least one of these relevant outcomes (participation, weight control, pain, health care cost or utilization, patient satisfaction, retention, general well-being) over 6 months from start of intervention or exposure; study is a full publication (not an abstract) in a peer-reviewed publication, is in English, and is conducted in North America, Western Europe, and Australia/New Zealand. Studies without a control group or studies of health-plan-sponsored access to inpatient or rehabilitation facilities.
Information to answer the key questions will be abstracted from the selected articles into a customized DistillerSR database and quality assessment of the articles will be performed using the key criteria described in the AHRQ methods manual adapted to this specific topic. We will synthesize the findings and, if feasible, perform a meta-analysis to compute a summary estimate of effect. The strength of evidence for key questions will be assessed using the AHRQ's Methods Guide for Effectiveness and Comparative Effectiveness Reviews.
Group Visits Focusing on Education for the Management of Chronic Conditions in Adults
Background and Objectives of Review
The Patient Aligned Care Team (PACT) has prioritized group visit implementation as part of their new primary care model. This review is a companion to the shared medical appointments (SMAs) review, which is being conducted by the Durham ESP. The shared medical appointments review will focus its attention on visits that are led by a physician or other licensed independent practitioner, which may or may not include other support staff. This current group visits review will focus on literature which describes the effectiveness of and various programmatic methods of group visits that have an emphasis on health education and are led by non-licensed independent practitioners such as nurse educators. This review will focus on chronic disease self-management and will exclude interventions that rely solely on support groups without including an educational component to the group visit.
Key Questions and PICOTS
The objectives of this review are to understand whether group visits are more effective than usual care, and whether group visits are more effective for specific patient populations. To accomplish these objectives, we will consider the following key questions:
KQ1. In adults with chronic medical conditions, do group visits compared to usual care improve:
KQ2. For adults with chronic medical conditions, do the effects of group visits vary by patient characteristics? Characteristics of interest include medical diagnosis, severity of disease, and comorbidities.
KQ3. (Depending on the size and comparability of elements identified in the literature) Which components of GV are associated with greater intervention effects?
The PICOT used to guide these key questions are as follows:
Evidence-based guidance for developing shared medical appointments
Background and Objectives of Review
A shared medical appointment (SMA) is an approach to providing education, self-management, problem-solving skills, or medication management to groups of patients. SMAs have the potential to improve the outcomes of outpatient meidical care through peer-to-peer learning and multidisciplinary care. SMAs also have the potential to improve staff satisfaction for those who prefer to work collaboratively. The VA is promoting the use of SMAs; however, it is challenging for managers to identify the disease states, personnel, and implementation strategies most likely to impact chronic illness outcomes and be cost-effective. Therefore, we propose a synthesis of the current literature to describe the types of SMA evaluated, determine the effects of SMA in different populations and inform efforts to improve medical care provided through SMAs.
Key Questions and PICOTS
KQ1. For adults with chronic conditions, do shared medical appointments (SMAs) compared with usual care improve: (1) Patient and staff experience? (2) Treatment adherence? (3) Quality measures: process of care measures utilized by VA, NQF, or NCQA? or biophysical markers (e.g., blood pressure)? (4) symptom severity and functional status? (5) Utilization of medical resources or health care costs?
KQ2. For adults with chronic medical conditions, do the effects of SMAs vary by patient characteristics (e.g., specific chronic medical conditions and severity of disease)?
KQ3. Is the intensity of the intervention or the components used by SMAs associated with intervention effects?
General Search Strategy
We plan to conduct a review of the literature by systematically searching, reviewing, and analyzing the empirical evidence as it pertains to the research questions. We plan comprehensive searches of PubMed, EMBASE, PsychInfo, CINAHL,Web of Science and clinicaltrials.gov. Inclusion criteria will be the following: study designs recommended by the Cochrane Effective Practice and Organization of Care Group; sample population, adults >18 years of age with asthma, CAD, CHF, COPD, DM, hyperlipidemia, HTN, or combinations of these medical conditions; setting, outpatient population in a primary care, outpatient or specialty clinic/practice; intervention or exposure must be "a series of medical visits (>= 2) where one or more health care professionals (including a prescribing clinician) cares for a group of patients and the medical provider addresses each patient's unique medical needs individually, with the potential to make changes in medications, but in the context of a group setting"; comparator, usual care or other quality improvement strategy; study reports on at least one of the relevant outcomes > 3 months from randomization and initiation of intervention; study is a full publication (not an abstract) in a peer-reviewed publication, is in English, and is conducted in North America, Western Europe, and Australia/New Zealand. Outcomes of interest are patient and staff experience (e.g., confidentiality, satisfaction, etc.), medication adherence, biophysical markers of disease, symptom severity, functional status, health care utilization (e.g., hospitalizations, etc.) and cost. Study populations selected for substance abuse and/or inpatients will be excluded.
Information to answer the key questions will be abstracted from the selected articles into a customized DistillerSR database and quality assessment of the articles will be performed using the key criteria described in the AHRQ methods manual adapted to this specific topic. We will synthesize the findings and, if feasible, perform a meta-analysis to compute a summary estimate of effect. The strength of evidence for key questions will be assessed using the AHRQ's Methods Guide for Effectiveness and Comparative Effectiveness Reviews.
The Effects of Family Interventions on Patient Outcomes
Background/Objectives of Review: Two recent Public Laws (110-387 and 1963) expand VA authority to provide enhanced services as necessary in connection with Service Connected (SC) injuries and permit the same level of services for Non-Service Connected (NSC) injuries and illnesses. The recommended expansion of services termed "Family Mental Health Services" includes consultation, professional counseling, marriage and family counseling, and training. The purpose of this report is to systematically review the evidence regarding the effect of family-involved interventions on patient outcomes.
Key Questions, including PICOTS:
Key Question #1: What is the effectiveness and harms of family-involved interventions on adult patient outcomes?
Key Question #2: What is the effectiveness of family-involved interventions compared to traditional individually-oriented interventions on adult patient outcomes?
Population: Patients with condition of interest and their family members
Intervention: Family-involved care including counseling, therapy, education, and family-based treatment
Comparators: A. No treatment or placebo B. Individually-oriented treatment or usual care
Outcomes: Final patient outcomes include: symptom improvement, functional improvement, quality of life, length of stay, discharge disposition, utilization. Intermediate patient outcomes include: treatment attendance/adherence, social support for patients, patient satisfaction with care.
Timing and Setting are not restricted.
General search strategy: We will search MEDLINE and PsycINFO for randomized controlled trials and systematic reviews published in English Language from 1980 to the present. The search will focus on prevalent physical and mental health conditions relevant to VA. The search will also include terms for family members or non-professional caregivers or family/couples/marital therapy.
Treatment of Anemia in Patients with Heart Disease
Anemia is very common in heart failure and coronary heart disease (CHD) patients: observational studies suggest about one-third of heart failure and coronary heart disease patients are anemic. Anemia in heart failure and coronary heart disease patients is associated with poorer outcomes, including an increased risk of hospitalization, decreased exercise capacity, and poor quality of life.
Anemia in these patients may, in part, reflect the effect of common comorbidities such as chronic kidney disease and may also be related to chronic disease anemia caused by pro-inflammatory effects of the illness itself. Iron deficiency with or without concomittant anemia may also be associated with poorer outcomes. Despite the association with poorer outcomes, it is unclear whether treating anemia or iron deficiency will improve outcomes. Anemia treatment strategies in heart failure and coronary heart disease patients include erythropoiesis-stimulating agents with or without iron and red blood cell transfusions. Iron replacement in iron deficient patients with or without anemia has also been investigated. The objective of this evidence review is to evaluate the balance of benefit and harms of these treatments in heart failure and coronary heart disease patients.
To address this objective we will answer the following key questions:
- In patients with congestive heart failure:
- In patients with coronary heart disease:
- What is the evidence that the benefits or harms of any of the interventions varies with the starting hemoglobin level of the patient?
- What are the costs of broadly implementing treatment strategies in VA for patients with anemia below this threshold value?
Patients: Adult patients with congestive heart failure or coronary heart disease (post acute-MI, or chronic CHD) and anemia or iron deficiency.
Interventions:
Comparator: Usual care, placebo
Outcomes: mortality (all-cause and disease specific), hospitalization (all-cause and disease-specific), exercise tolerance (NYHA class, 6min walk test), quality of life, cardiovascular events (myocardial infarction, heart failure exacerbation, need for revascularization)
Timing: any
Setting: inpatient or outpatient
Research Integrity Literature Synthesis Literature Synthesis
A structured literature review will be performed to identify articles that describe Institutional Review Board (IRB) review of Quality Improvement (QI) research. This literature review aims to understand how IRBs approach QI research including selection of cases that require review, approach to patient selection and informed consent, issues in accessing data and approach to conflicts of interest. The IRB approaches described in the papers will be summarized including areas of variation and with a focus on areas where there is a dearth of published information.
My HealtheVet (MHV) Literature Synthesis
Proposed Study Selection: Peer-reviewed articles assessing the effects of select personal health record functionalities on clinical outcomes, patient-centered outcomes, and system-level outcomes, especially among organizations most similar to the VA.
POPULATION: include all studies in relevant peer-reviewed literature; make special note of VA peer organizations, i.e., integrated delivery systems whose experience with care delivery & on-line health activities may generalize best to the VA, including: Kaiser Permanente, Group Health Cooperative, Geisinger Health System, Partners Healthcare, and Palo Alto Medical Foundation.
FUNCTIONALITIES:
OUTCOMES:
Clinical outcomes: quality of care (performance measures, clinical processes); health outcomes
Patient-centered outcomes: patient satisfaction, provider satisfaction, quality of patient-provider communication, self-management, adherence (medication,visit)
System-level outcomes: efficiency, telephone medicine utilization, system workload, provider time, inappropriate use, privacy breaches, patient safety