Spotlight on Preventive Care Research
The goal of preventive care is to stop disease from occurring before it can become either life-changing or life-limiting. Preventive care can include everything from daily exercise to vaccines to routine cancer screening exams. Within VA, preventive care programs and policies are guided by the National Center for Health Promotion and Disease Prevention (NCP). The NCP advises VA leadership on evidence-based health promotion and disease prevention efforts designed to enhance Veterans’ health, well-being, and quality of life. To help support NCP’s mission, VA’s Health Services Research and Development (VA HSR&D) service conducts research that builds the evidence base for both primary and secondary prevention efforts. Primary prevention research looks at how VA can best promote Veterans’ health; identify risk factors for developing a new health condition (e.g., disease, disorder, injury); and prevent the onset of a new health condition. Secondary prevention research is designed to identify risk factors for the progression or recurrence of a health condition, and to detect and prevent progression of an asymptomatic or early-stage condition.
The following studies are just a few of the ongoing and recently completed HSR&D-funded investigations into preventive care research.
Regular preventive care can help improve early detection of life-limiting or life-altering diseases, particularly colorectal cancer (CRC). A commonly accepted component of assessing risk factors for many chronic diseases is collecting a family health history (FHH); however, it is rarely used in clinical practice as part of a structured risk assessment. Given that VA currently has no system-wide, comprehensive, method to assess FHH or provide decision support, investigators in this study expect that a standardized FHH assessment (accompanied by decision support) should help:
- Increase identification of patients at higher risk for CRC;
- Improve genetic consultation referral for patients at risk for hereditary cancers; and
- Support the recommendation of guideline-based preventive care for all patients at risk.
About the Study
The goal of this study is to evaluate the feasibility and effectiveness of the Genomic Medicine Model (GMM) in capturing FHH to identify patients at increased risk for CRC. The GMM: 1) provides education to physicians, patients, and communities on the importance of FHH; 2) contains a health IT-based platform (MeTree) that uses patient-entered data to risk-stratify patients and generate risk-stratified, evidence-based preventive care recommendations for physicians and patients; and 3) provides resources to patients and providers to effectively interpret FHH information and adhere to recommendations.
Using a mixed methods approach, investigators will:
- Determine whether FHH collection via MeTree improves identification of patients at higher familial risk for CRC by comparing rates of high-risk identification in the medical record prior to study enrollment to rates of high-risk identification following MeTree completion.
- Evaluate whether providing decision support to patients and primary care providers (PCPs) improves risk-appropriate referrals for, and patient uptake of CRC screening/surveillance.
- Assess experience with decision support and effects on workflow from PCPs and obtain information to inform eventual implementation in the VA healthcare system.
- Conduct cost-consequence and budget-impact analyses of implementing FHH collection and GMM decision support in VA.
Investigators will conduct a retrospective chart review of eligible patients aged 40-65 years who are enrolled in primary care, do not have a personal history of CRC, and have some knowledge of FHH. Chart reviews will help determine the baseline rate of documenting FHH of CRC in the medical record for patients enrolled. Further, patients will be randomized to provide FHH (entered by patient) and receive patient and provider decision support at enrollment or 12 months later. Interviews will be conducted with physicians and clinic leaders, and data will be analyzed. Finally, investigators will conduct a budget impact analysis. This study was recently completed and data analyses are underway.
Corinne Voils, PhD, is an affiliate investigator and HSR&D Research Career Scientist awardee with the William S. Middleton Memorial Veterans Hospital in Madison, WI.
This study has resulted in the following publication:
Goldstein KM, Fisher DA, Wu RR, et al. An Electronic Family Health History Tool to Identify and Manage Ptients at Increased Risk for Colorectal Cancer: Protocol for a Randomized Controlled Trial. Trials. 2019 Oct 7; 20(1):576.
Vascular disease of both the heart and brain (cardiovascular disease, or CVD) results in greater national and global mortality than any other chronic condition, and it disproportionately impacts minority patients using VA care. A common feature of most chronic disease care is that decision-making is not just a matter of whether, but when to intervene, and of the available treatments, which should be used first. Further complications for decision-making include lack of integration of blood pressure, lipid, and American Heart Association and American Stroke Association guidelines, as well as the fact that risk factors and treatment effects on heart attacks, stroke, congestive heart failure, and renal disease vary substantially—yet guidelines remain simplistic.
Study results may have far-reaching implications in that they may substantively improve primary CVD treatment choices by dramatically advancing how VA clinicians use existing historical clinical data and by integrating alternative treatment options through analysis of their strengths, weaknesses, and differential impact on various CVD outcomes. Pending results and implementation, the impact of this work on the VA healthcare system, and on Veterans’ quality of life and mortality, should be significant.
About the Study
In this study, investigators are examining the degree to which longitudinal baseline patient data improves predicting overall CVD risk—the key determinant of absolute risk reduction for statins and other blood pressure medications. Second, investigators are developing and validating for a model to measure errors and outcomes in VA’s electronic health record (EHR CVD risk predictor. Finally, investigators will create an estimate of how the timing, order, and intensity of treatment impact CVD risk reduction within an integrated CVD prevention framework.
A 13-year longitudinal assessment of VA’s electronic health record (EHR) featuring Veterans age 45 to 80 will combine data from VA, the National Death Index, the Centers for Medicare and Medicare Services, VA data and focused chart reviews. Investigators will test a series of hypotheses trying to understand the relationships of risk factors to different CVD risks—and to improve patients' risk stratification, a key factor for estimating absolute risk reduction. The validity of those findings will then be tested.
Finally, investigators will evaluate an integrated optimal approach to considering anti-hypertensive, lipid-lowering and anti-platelet therapy simultaneously.
Rodney Hayward, MD, is an investigator with the HSR&D Center for Clinical Management Research, in Ann Arbor, MI in Ann Arbor, MI.
Implications: Preventing Type 2 diabetes mellitus (T2DM) is an important way to improve Veterans' health and limit the burden of T2DM on VA care. Yet despite the availability of evidence-based strategies to prevent T2DM, engagement among at-risk Veterans is low. A critical opportunity to engage Veterans it preventive strategies may be when they learn they have prediabetes (blood sugar levels are abnormally high but not high enough to be diagnosed with diabetes); however, it remains unclear how VA communications to those Veterans could be optimized to improve overall participation. Insights resulting from this HSR&D Career Development Award research will help identify new opportunities to improve Veteran engagement in evidence-based ways to prevent T2DM. It is expected that results will translate to other high-priority conditions in which Veterans’ engagement in preventive behaviors is essential and could be improved.
About the Study
In this ongoing study, investigators are:
- Describing at-risk Veterans' current engagement in behaviors to prevent T2DM as well as the mediators of that engagement.
- Examining the impact of a prediabetes diagnosis on a-risk Veterans' weight and engagement in behaviors to prevent T2DM.
- Understanding the effects of five behavioral economic and health psychology strategies on weight, HbA1c, and engagement in behaviors to prevent T2DM among Veterans with prediabetes.
To date, 369 non-diabetic Veterans with risk factors for T2DM have been surveyed about their engagement in prevention behaviors and mediators of this engagement, including risk perception, motivation, and awareness of and preferences for preventive strategies.
To examine the impact of a prediabetes diagnosis, investigators are conducting a pilot, randomized trial among 315 non-diabetic Veterans, 252 of whom were randomly assigned to undergo screening for T2DM using a hemoglobin A1c (HbA1c) test. Of this group, 63 Veterans were not screened using the A1c test. The remaining 107 Veterans who were found to have HbA1c values in the prediabetes range received preventive recommendations via brief standardized counseling. All 315 Veterans in the study group are having their weight tracked and are being surveyed immediately after the screening and brief counseling process, at 3 months, and at 1 year.
Across the 107 Veterans found to have prediabetes and the 63 who were not screened, investigators are comparing weight, T2DM preventive behavior engagement levels, and mediators of engagement. In order to gain insights into the effects of the diagnosis and counseling, 20 semi-structured interviews have been conducted among the prediabetes group.
Finally, among 144 Veterans who, at baseline, had a recent HbA1c test result in the prediabetes range but were not engaged in an evidence-based strategy to prevent T2DM, investigators are evaluating the effectiveness of five innovative health psychology and behavioral economic strategies to promote initial engagement in T2DM preventive behaviors.
Jeffrey Kullgren, MD, MPH, is an investigator and Career Development Award program recipient with the HSR&D Center for Clinical Management Research, in Ann Arbor, MI.
This study has resulted in the following publication:
Leung CW, Kullgren JT, Malani PN, et al. Food Insecurity Is Associated with Multiple Chronic Conditions and Physical Health Status Among Older US Adults. Preventive Medicine Reports. 2020 Sep 20; 101211.
Implications: Lifestyle behaviors such as tobacco use and physical inactivity lead to conditions (cancer, heart disease, stroke) that account for almost 50% of mortality in Veterans using VA care. While VA has made significant improvements in helping Veterans control certain diseases, it has not done as well in addressing those underlying behavioral factors. This study was the first to test an intervention that connected results from VA’s HealtheLiving Health Risk Assessment (HRA) with a telephone-delivered health coaching shared decision-making (SDM) intervention designed to help participants enroll in a structured preventive health program.
Results indicated that the degree of prevention program enrollment (over half enrolled, and 40% participating by six months) was much higher than reported in other studies that seek to engage primary care patients in prevention programs. The implications for the study results are encouraging, as the intervention is a relatively low-resource approach that leverages already-available VA prevention programs and requires less time than would be necessary to address changing specific behaviors. Further, such a program may increase reach because many patients prefer telephone coaching for its convenience and personal approach. Investigators are now focusing on incorporating this low-resource intervention into routine primary care practice.
About the Study
The objective of this study was to determine if a telephone-based SDM using VA's web-based Healthe Living Assessment, in concert with a Prevention Coach, would increase patient activation and enrollment in preventive care programs as compared to usual care. The study was a conducted at the Durham and Ann Arbor VA Medical Centers.
A total of 436 eligible Veterans were identified via phone screening, and of those, 417 were randomly assigned to receive the intervention or usual care. Eligible Veterans had at least one modifiable risk factor (obesity/overweight, physically inactive, or tobacco user) but were not currently enrolled in a prevention service. The brief telephone intervention was conducted by a prevention coach and used the output from VA's HRA to engage Veterans in a conversation where individual preferences were matched to behaviors and choices for specific prevention services, either in VA or the community.
Health coaches were successful in engaging participants in a discussion about prevention and guiding them to a program that matched their goals, which resulted in intervention participants enrolling and participating in programs to a significantly greater degree (40% vs. 23%) than the participants not receiving coaching (usual care). Intervention participants also showed significant improvement in Patient Activation Measure (PAM) scores, a measure that captures patients' knowledge, skills, and confidence in managing their health.
At six months, intervention participants reported higher enrollment in a prevention program, 51% vs 29% and higher participation in a prevention program, compared to usual care participants. There was no difference in PAM scores between groups at the one month assessment. However, at six months after baseline, intervention participants showed greater improvement in PAM scores than usual care participants.
Principal Investigator: Eugene Oddone, MD, MHSc, is an investigator with the HSR&D Center to Accelerate Discovery and Practice Transformation, in Durham, NC.
This study has resulted in the following recent publications: