July 2018

Spotlight on Evidence-Based Practice (EBP)

Background

Evidence-Based Practice (EBP) has been defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.” It brings together evidence from systematic research, clinical expertise, and patient values and preferences.¹ Evidence-based practice in HSR&D allows practitioners to apply clinical guidelines, research, and high quality patient-based findings to healthcare delivery,² improving Veterans’ healthcare experiences and health outcomes.

Two HSR&D programs, the Quality Enhancement Research Initiative (QUERI), and the Evidence-Based Synthesis Program (ESP), support Veteran care through EBP. Since 1998, QUERI has been committed to ensuring that research gets used effectively to ultimately sustain improvements in care for Veterans. QUERI’s national network of 200+ clinicians and experts in health services research collaborate with VA leaders, administrators, and frontline providers to achieve QUERI’s three-fold mission to:

• Rapidly translate research findings and evidence-based treatments into clinical practice
• Increase the impact of research findings through bi-directional partnerships and rigorous evaluations
• Promote implementation science and support VA’s transformation to a learning healthcare system³

ESP exists under the QUERI umbrella. The program consists of four ESP Centers, each with an active University affiliation, and a Coordinating Center. The ESP offers a range of products, from rapid review evidence briefs to full systematic reviews, tailored to the needs of decision-makers. In addition to being made available throughout VA and in the public domain, ESP reports are also published in top medical journals, so that clinicians worldwide may access them, and some evidence syntheses have informed the clinical guidelines of large professional organizations.⁴

The following studies highlight HSR&D projects that implement Evidence-Based Practice across VA, to continuously improve Veteran care.

• Improving Pain-Related Outcomes for Veterans (IMPROVE)
• Complementary and Integrative Health Evaluation Center
• Systematic Review: Access Management Improvement
• Effects of Cannabis among Adults with Chronic Pain

Improving Pain-Related Outcomes for Veterans (IMPROVE)

Among Veterans treated in the VA healthcare system, chronic pain affects up to 50% of patients and is a major contributor to poor health-related quality of life. VA primary care teams report feeling overburdened, under-resourced, and generally ill-equipped to meet the needs of Veterans with chronic pain. This can lead to low-quality and sometimes unsafe pain care.

To improve function and quality of life and also decrease morbidity and mortality among patients with chronic pain, a growing body of research evidence and expert consensus support multi-modal pain care. In this type of care, evidence-based non-pharmacologic (non-drug) treatment modalities are incorporated alongside pharmacologic treatment, with reduction in high-dose opioid therapy and avoidance of opioid-benzodiazepine combination therapy.

The goal of HSR&D’s Quality Enhancement Research Initiative (QUERI) is to implement evidence-based practice rapidly into routine care and improve the quality and safety of care delivered to Veterans. To address needs for specific strategies and tools, the Improving Pain-Related Outcomes for Veterans QUERI program has assembled an expert team of implementation scientists and clinical researchers with extensive expertise in pain management - and has partnered with clinical leadership to create a consortium of inter-related and complementary projects that address quality gaps in pain care. Specific project objectives include developing and refining implementation tools and strategies that facilitate uptake and increase access to evidence-based, multi-modal pain management services.

Project Summaries:  

Cooperative Pain Education and Self-management (COPES):  This project focuses on reaching Veterans who currently do not have access to pain management resources by providing cognitive-behavioral therapy for pain through an automated Interactive Voice Response system. Successful implementation of this system could provide a foundation for future work on similar interventions to improve chronic illness care cost-effectively using mobile health models.

Primary Care-integrated Pain Support (PIPS):  This project studies the implementation of a pharmacist-led care management strategy designed to decrease the number of Veterans receiving high-dose opioid and combination opioid-benzodiazepine therapy, while increasing their engagement with non-pharmacologic pain treatment.

Academic Detailing Quality Improvement:  In this quality improvement project, interviews were conducted with academic detailers and providers from VISN 21 (Sierra Pacific) to evaluate the Pharmacy Benefit Management Services’ opioid-prescribing practices. Interviews with academic detailers revealed challenges and strategies for engaging providers as well as the importance of leadership support at the clinic and executive levels. Provider interviews confirmed the importance of leadership support, including the need for protected time to meet with academic detailers, and also revealed the value of tailoring information to provider setting and patient population.

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Complementary and Integrative Health Evaluation Center

Complementary and integrative health (CIH) approaches such as acupuncture, mindfulness meditation, and yoga are important safe, non-pharmacologic options to improve health with few side effects. The provision of evidence-based CIH approaches is a national priority for the VA healthcare system and is part of the 2016 Comprehensive Addiction and Recovery Act (CARA). Funded by HSR&D’s Quality Enhancement Research Initiative (QUERI), the overarching goal of the Complementary and Integrative Health Evaluation Center (CIHEC) is to improve Veterans’ health and experiences of care through increased availability and use of evidence-based CIH approaches. To accomplish this goal, CIHEC is partnering with several program offices, including VA’s Office of Patient Centered Care and Cultural Transformation (OPCC&CT), Office of Analytics and Business Intelligence (OABI), and National Pain Management Program.

Project Summaries:  

Veteran Preference for and Utilization of CIH collected data on Veteran demand for, use of, and barriers to CIH approaches, via the Veteran Insights Panel of 3,200 Veterans.

• In the past year low percentages of Veterans (9-23%) used massage, chiropractic, meditation/mindfulness, yoga, progressive relaxation, and acupuncture therapy. More than half in the study were interested in trying/learning more about each of the six CIH approaches, but face many barriers.
• The majority of Veterans are unaware of the CIH approaches that already exist at their local VA facilities.

Environmental Scan is an online survey of all CIH program leads in VA to learn details of what, when, where, and by whom CIH is being delivered, as well as what implementation barriers they face.

• VA sites offered an average of 5 CIH approaches, with the most common being relaxation techniques, yoga, Mindfulness-Based Stress Reduction, meditation, and Tai chi.
• National survey results will help OPCC&CT understand how CIH approaches are being offered—and how they can be better implemented across VA.
• The database of all VA CIH program leads that have been generated will facilitate communication across those leads and OPCC&CT.

PRIMIER-I improves the implementation of CIH-related patient reported outcome (PRO) data collection in usual care settings by developing and evaluating facilitation strategies for changing clinical work flow processes and collecting PROs at the point of care.

• Researchers are testing two strategies for the electronic collection of CIH-related patient reported outcomes to inform OPCC&CT’s implementation blueprint for collecting PRO data nationally.

Battlefield Acupuncture (BFA) is examining the effectiveness of VA’s Pain Management Program’s auricular acupuncture protocol (BFA) on pain, and barriers and facilitators to its implementation, providing another example of how VA leads the nation in pain management options.

• Preliminary results show BFA reduces pain. However, given that BFA is a new protocol, BFA-trained providers face several implementation barriers and offer a few strategies to overcome those barriers.
• OPCC&CT can use this information to address implementation barriers and foster the training of additional BFA providers.

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Systematic Review: Access Management Improvement

Access to timely primary care is important since primary care providers both diagnose and treat most common conditions and also act as the entry point to more specialized care. Primary care access management involves the consideration of various interacting system parts and goals, including continuity, team roles, and management structures. This systematic review sought to determine what evidence is available regarding primary care access management strategies in an organized and accountable healthcare delivery system such as VA. The West Los Angeles-based Evidence-based Synthesis Program team searched the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed for relevant literature related to group practice management and access or accessibility. Key questions and answers were:

What definitions and measures of intervention success are used, and what evidence supports use of these definitions and measures?

• In studies of management interventions to improve primary care access, the third next available appointment is believed to be a more stable measure of access than the first or second available appointment, thus was the most commonly used measure of success (74%), followed by continuity and patient satisfaction.

What are the key features of successful (and unsuccessful) interventions for organizational management of access?

• The most common intervention components were: 1) reducing the backlog of appointments, 2) using fewer appointment types, and 3) producing regular activity report. However, whether or not these are key features of success cannot be determined from the data, nor whether organizational commitment is as, or more important than any particular features.
• Some studies of longer than one year duration reported more mixed results, with rising wait times and the need for modifications to the access management strategy reported in two large, long-term studies.

Are relevant, tested tools, toolkits, or other detailed material available from successful organizational interventions?

• Several tools or guides were identified for improving primary care access four from settings linked to implementation studies, one from a VA setting, two from the Institute for Healthcare Improvement (IHI), one from the National Health Service (England) and two online tools from Canada.

Conclusions

Most studies reported dramatic improvements in access over the short-term, but the more mixed results reported in studies of longer duration suggests that gains in access are difficult to sustain.

Miake-Lye IM, Mak S, Shanman R, Beroes JM, Shekelle PG. Access Management Improvement: A Systematic Review. VA ESP Project #05-226; 2017.

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Effects of Cannabis among Adults with Chronic Pain

The use of cannabis for medical purposes has become increasingly accepted in the U.S. Up to 80% of individuals who seek state-sanctioned medical marijuana do so for pain management. In fact, nearly 40% of Veterans prescribed long-term opioid therapy for chronic pain add treatment with cannabis. Investigators with VA’s Evidence-based Synthesis Program (ESP) Center searched multiple data sources to assess the efficacy of cannabis for treating chronic pain and provide a broad overview of the short- and long-term physical and mental health effects of cannabis use in chronic pain. Findings were:

• Investigators found low-strength evidence that cannabis may improve pain in some Veterans with neuropathic pain. Studies generally did not find clinically significant differences on continuous pain scales between groups. A higher proportion of intervention patients experienced clinically significant pain relief over the short-term, but there is very limited evidence about the effects over weeks to months of follow-up.

• Moderate-strength evidence suggests that light to moderate cannabis smoking does not adversely impact lung function over about 20 years. However, there is limited evidence that daily use may have a harmful effect on lung function over time. There is no evidence examining safety in older patients, or those with multiple medical comorbidities.

• There is a consistent association between cannabis use and the development of psychotic symptoms over the short and long term. There is moderate-strength evidence that cannabis intoxication is associated with an increased risk of being involved in a motor vehicle accident.
• Cannabis appears to be associated with at least small, short-term damaging effects on cognition in active users, but long-term effects in past users are uncertain.

Implications:   

• There is virtually no conclusive information about the benefits of cannabis in chronic pain populations and limited information on harms, so methodologically strong research in almost any area of inquiry is likely to add to the strength of evidence.

This review resulted in the following publication(s):

Nugent S, Morasco B, O’Neil M, et al. The Effects of Cannabis among Adults with Chronic Pain and an Overview of General Harms: A Systematic Review. Annals of Internal Medicine. September 5, 2017;167(5):332-40.

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References

1. What is Evidence-Based Practice (EBP)? [Internet]. Durham (NC): Duke University; 2018 [cited 2018 June 19]. Available from: https://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021
2. Evidence-Based Practice [Internet]. Pitman (NJ): Academy of Medical-Surgical Nurses; 2018 [cited 2018 June 19]. Available from: https://www.amsn.org/practice-resources/evidence-based-practice
3. QUERI – Quality Enhancement Research Initiative [Internet]. Washington (DC): US Department of Veterans Affairs; 2017 [cited 2018 June 19]. Available from: https://www.queri.research.va.gov/about/default.cfm
4. Evidence-based Synthesis Program [Internet]. Washington (DC): US Department of Veterans Affairs; 2017 [cited 2018 June 19]. Available from: https://www.hsrd.research.va.gov/publications/esp/default.cfm

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