Updates from HSR&D Central Office
July 21, 2021
By Naomi Tomoyasu, PhD, Deputy Director of VA HSR&D
Naomi Tomoyasu, PhD, Deputy Director of VA HSR&D
Although COVID has profoundly impacted us, the good news is that things appear to be slowly and cautiously returning to normal–or at least the new normal. Health services research has continued to march ahead with resilience and might despite the pandemic. However, COVID has highlighted again the health disparities experienced by Veterans from communities facing discrimination and who are otherwise under-represented. What is hopeful is that notable positive changes have been occurring at the national level and new and exciting Diversity, Equity, and Inclusion (DEI) programs have been launched!
First, the White House released an Executive Order which establishes a government-wide initiative to advance diversity, equity, inclusion, and accessibility in all parts of the Federal workforce. Led by the Office of Personnel Management and the Office of Management and Budget, in partnership with the White House and the Equal Employment Opportunity Commission, this Initiative will advance opportunities for communities that have historically faced employment discrimination and professional barriers, including: people of color; women; first-generation professionals and immigrants; individuals with disabilities; LGBTQ+ individuals; Americans who live in rural areas; older Americans; parents and caregivers; people of faith who require religious accommodations at work; individuals who were formerly incarcerated; and Veterans and military spouses. We’ve been making great research strides with many of these groups and will continue to do so in the coming months and years.
In alignment with the Executive Order, there are also several noteworthy changes that will promote and support DEI activities within ORD. One significant event is the launch of a formal ORD-wide Diversity, Equity, and Inclusion Workgroup with a clear mission statement, a charter, and a Stakeholder Engagement Board that will provide recommendations to enhance DEI research and recruit and retain a more diverse workforce. A significant characteristic of this workgroup is that it has been backed with funds from the Chief Research and Development Officer, Dr. Rachel Ramoni. Close to $2.5 million has been committed to this DEI effort within ORD, including support to research supplements to 10 outstanding early career investigators from under-represented groups and their mentors. Of the 10 applications awarded in the program’s first year, 4 were awarded to HSR&D researchers! This highlights the extraordinary pool of senior and early career investigators in health services research who were successfully able to achieve these funds due to their deep commitment and expertise in DEI research.
Another noteworthy event is the launch of the first HSR&D DEI workgroup to increase representation of under-represented groups, including racial/ethnic minorities, specifically in health services research. The work of this group has already led to several accomplishments this year including a training and career development program started this summer by HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR) (led by Dr. Keith McInnes) for medical students from under-represented racial and ethnic groups in partnership with the Boston University School of Medicine. In addition to the ongoing DEI training and projects that workgroup members have already launched locally, the workgroup also has begun a series of interviews (led by Dr. Christine Hartmann) to assess the experiences, insights, and opinions of researchers and staff from under-represented ethnic/racial minority groups within VA. An additional objective of these interviews is to identify barriers and facilitators to retention of racial and ethnic minority researchers focusing on both interpersonal and structural factors that may benefit some groups more than others. Based on the recommendations of this workgroup, HSR&D will also initiate new mentoring and training opportunities and develop new or enhance existing research funding mechanisms that highlight the importance of diversity in health services research.
Lastly, this year’s Under Secretary’s Award for Outstanding Achievement in Health Services Research was awarded to Dr. Donna Washington for her incredible accomplishments in the field of diversity, equity, and inclusion and women’s health. The competition was fierce as the nominees for this award are also phenomenal researchers and attests to the amazing pool of researchers that HSR&D has been honored to partner with over the years!
June 23, 2021
By David Atkins, MD, MPH, Director of HSR&D
David Atkins, MD, MPH, Director, HSR&D
As vaccinations increase and COVID cases fall, I hope many of you have felt the freedom to resume parts of your pre-COVID existence. In the past few weeks, I have bicycled into the office, flown to see my youngest son, watched a movie in a theatre, and attended live music. The last of these – the chance to convene with a group of strangers connected only by a love of live music and a particular musician (Richard Thompson, a legend of the British folk scene since the early 70’s) -- felt especially poignant. At the same time, it is also clear that our pre-COVID work world is not coming back. In the Office of Research and Development we are assessing how best to balance the clear benefits of telework (shortened commutes, less pollution and traffic, lower stress on those with parenting or caregiving duties) with the value of being together in person (ease of communication, team building). Individual VAMC’s and research divisions across VA are engaged in the same discussions. While the past year demonstrated that HSR&D researchers can work effectively in a 100% virtual environment, it didn’t demonstrate that this is the best way to work. We lose something important when we only see each other on a laptop screen. There are no serendipitous meetings on Zoom, no ducking into someone’s office at the end of the day to bounce off a new idea, no casually checking in on someone who seems a little down. At the same time, we are also realizing in ORD that a more virtual work environment, where employees don’t need to relocate to DC, could greatly expand our ability to recruit staff. We are listening to our staff carefully to try to create a “future of work” that optimizes the productivity and experience of each individual and each work unit while being equitable to all.
I had similar thoughts in attending the virtual AcademyHealth Annual Research Meeting this month, the second straight year it has been virtual. The plenary sessions were excellent and offered the advantage that people could pose questions live in the chat rather than racing to a microphone. Was it significantly worse to watch speakers up close on my laptop vs. on a screen in a cavernous conference hall? The pre-recorded abstract sessions also worked well, and I loved being able to watch sessions asynchronously rather than having to choose among competing sessions. The lower cost of meeting virtually should widen access to the conference and I thought of how much lower the carbon footprint was with thousands of foregone plane flights. Despite all of these advantages, however, attendance was down again this year, for the simple reason that people prefer to meet in person. We love the chance to travel not because we love cramming into an airplane but because it is the only way to get away from the constant demands of our office and clinical duties so that we can open ourselves to learning new things. As hard as I try, I can’t carve out the same protected space when I try to attend virtual conferences from the office or from home. Equally important, they haven’t yet come up with the virtual equivalent of running into old friends on the escalator, getting career advice over dinner, or being introduced to rising young stars (or conversely, to eminent research “all stars”). The importance of forming or recharging that sense of shared purpose and community can’t be discounted. (Has a successful cult ever been formed on WebEx?)
With this background, we were glad to see the recent VA memo removing the freeze on travel. We have told COINs that they can begin holding their Stakeholder Forum meetings in-person and we are offering support for some small field-based research meetings. Although we opted for a virtual CDA meeting in the Fall, HSR&D is submitting a request for a National HSR&D/QUERI meeting for summer 2022. This will mark almost 3 years from our last meeting in DC in the midst of Washington World Series fervor. I promise I will be less distracted if we meet in July. I and the rest of the HSR&D leadership team will be resuming travel this summer provided COVID numbers keep improving. We look forward to meeting you again in your native habitat – I hope you won’t be offended if I offer you a hug on reuniting.
May 18, 2021
By David Atkins, MD, MPH, Director of HSR&D
HSR&D recently completed our winter round of Scientific Merit Review Board (SMRB) meetings. The results of those meetings, in terms of projects approved for funding, are now available online. The good news is that we’ve been able to sustain a stable level of project funding for investigator-initiated research (IIR) proposals as shown in the graph. The 108 submissions and 24 projects approved for funding this last round represent our highest numbers of the last 4 cycles. The process of scientific review and funding decisions, as at NIH, consists of two steps: the scientific review, conducted by 8 separate review panels made up of VA and non-VA reviewers chosen for their scientific expertise; and an administrative review, conducted by HSR&D leadership with input from the individual scientific program managers (at NIH this function is fulfilled by their Councils).
The administrative review is intended to address several factors that may get overlooked or inconsistently addressed in the scientific review: 1) does the project significantly overlap other work already funded within VA or at NIH? 2) were there important concerns raised that are not reflected in overall scores? 3) are there time-sensitive opportunities that make funding at this time important? 4) is this project of unique value to HSR&D, ORD, or VHA priorities or, conversely, are there potential issues that may make it unlikely for the research to be scalable in VA? 5) is the recruitment plan, for clinical studies, realistic and supported by pilot data? and 6) is a 3-4 year study the most appropriate way to achieve the aims of the project? Much of the administrative review is devoted to projects which are near the funding cutoff and involve assessing whether they are ready for funding or would benefit from an additional submission. Finally, we give special attention to proposals from early investigators or in areas of particular importance to HSR&D, ORD, or VA.
The administrative review largely defers to the judgment of the scientific review experts about study design and scientific contribution, but due to the factors described above we may decide we need additional discussion with applicants. Only rarely do we choose NOT to fund a project that has scored very well in review. Such cases usually involve excessive overlap with an existing project or a judgment that there are insurmountable hurdles to the study working in VA. In one example, a study proposed to develop and test a web-based solution for prevention, not realizing that the program office had already committed to using a different federally-supported web tool. Releasing the list of projects at the early “approved for funding” stage is our attempt to reduce the problem of unwitting overlap – it can take six months or longer from approving a project for funding to completing all the regulatory steps and having the project funded and listed on the HSR&D website or grants.gov. To prevent the second type of problem, we encourage early and frequent communication with partners and are working to expand venues such as our Consortia of Research (CORes) to promote regular communication between partners and the larger research community.
Rather than deny funding to a promising project, we may require closer collaboration with partners, ask for some modifications to design, fund a component of a project, ask for an accelerated timeline, or provide funding contingent on meeting early milestones. In one case, where we had concerns that the model being tested required new staff that would not be supported by facilities or VISNs, we provided partial funding for the investigator to work with stakeholders to determine how to make their model viable. One personal observation that these discussions have reinforced is that researchers tend to approach every issue as a problem of knowledge: they believe that if only we could perfect our understanding of exactly what is happening and why, through deep quantitative and qualitative analysis, we could devise a perfect solution that everyone would embrace. The reality, I think, is that many issues in healthcare reflect the challenges of more consistently implementing what we already know. In some cases, we’ve asked investigators to compress the process of developing and refining their intervention to focus more on how to implement that intervention effectively and feasibly in practice. As HSR&D funds implementation research, we encourage investigators to think about hybrid effectiveness-implementation studies to address effectiveness and implementation at the same time. We are fortunate to have a growing QUERI program that has several training hubs that provide HSR&D investigators with guidance on designing and deploying hybrid implementation studies. Scientific peer review remains the bedrock of our research program – it’s how we prevent wasting money on bad science or chasing transient issues. We are incredibly grateful to the contributions of our volunteer reviewers and to the work of our scientific program managers, our SMRB staff, and our contractors who make the process run smoothly (see the profile of Liza Catucci who manages this process in HSR&D). Here’s to the hope that as the pandemic subsides, we may meet again in person next year.
April 5, 2021
By David Atkins, MD, MPH, Director of HSR&D
When the first day of spring arrived last month, it felt that we had just endured a year-long winter, one without trips to the office, visits with family, or children heading off to school. Far grimmer has been the toll on patients with COVID, the families mourning loved ones, and the clinicians bearing the weight of it all. The initiation of this monthly “Updates from HSR&D Central Office” is a recognition that one the of major casualties of the past year has been communication with the field as my usual venues to connect with you have all been put on hold – field visits, national conferences, and our national HSR&D/QUERI meeting.
The good news is that it seems permissible to be hopeful this spring – hospitalizations and deaths continue to decline in most parts of the country as the numbers vaccinated climb steadily. With the hope that an even brighter summer lies ahead, here are some reflections on what I learned the past year:
- Given a challenge, our researchers respond with amazing creativity. A March survey of our COINs identified over 200 COVID publications in the past year, many without dedicated research funding.
- VA is an ideal system to study COVID due to the quality of our data, depth of our research community, and the consistency of our clinical response. Unlike in many other systems, COVID outcomes in VA aren’t confounded by lack of access or overwhelmed hospitals. Teams from VA were some of the first to publish results within a large FDA collaboration of different health care systems using EHR data to assess new COVID treatments.
- Our HSR&D staff and our researchers can work very effectively in a remote environment. We are unlikely to go back to a world requiring 100% office work, especially in areas where commuting can waste more than 2 hours a day.
- It’s hard to manage a national public health crisis with a hodgepodge of Federal, state and county responsibilities. Nothing made clearer the value of a national, integrated system than VA’s success in vaccinating staff and patients.
- I miss the office and even my commute – Zoom makes casual interaction much harder, and it’s difficult maintaining the continuous informal connections that make a team work well. And Zoom coffees or birthdays without the pastries and cakes are for the birds.
- Even setting aside new variants, we still have so much to learn about COVID. A new effort in HSR&D will bring national data to bear to study the long-term outcomes of the 250,000 Veterans who recovered from COVID, including those who seem to suffer from what is now known as PASC – post-acute symptoms of COVID. A separate set of initiatives is examining the effects of pandemic disruptions to work and healthcare on non-COVID outcomes such as suicide, substance use and other mental health outcomes, the care of acute conditions and the management of chronic diseases. VA has experienced far more excess deaths in 2020 than are officially attributed to COVID, but we don’t know the relative contribution of social disruption, delayed or suboptimal health care, or undetected COVID.
I truly hope and believe we will be able to put the worst of COVID behind us over the coming year, but I also know the process of fully understanding COVID will take years of work from dedicated and creative researchers. I am so proud that so many of them work in VA.