VA Research on the Hill
by David Atkins, MD, MPH
June 5, 2018
This article originally appeared on the HSR&D Perspectives blog (on the VA intranet).
Two events on Capitol Hill last month helped crystalize the challenges and opportunities facing VA research in a still fluid political environment. The first was a joint hearing on "VA Research: Focusing on Funding, Findings, and Partnerships." Held on May 17, 2018 before the House Committee on Veterans' Affairs Subcommittee on Oversight and Investigation, the hearing featured Carolyn Clancy, MD, VHA Executive in Charge, and Rachel Ramoni, DMD, ScD, VA's Chief Research and Development Officer, who spoke about VA research priorities, processes, and academic relationships. Over the course of a sometimes contentious hearing, several committee members aired several complaints about VA research:
- With its broad scope of research on conditions prevalent among Veterans, VA research is insufficiently focused on those specific to Veterans; for example, Gulf War-related health problems, Agent Orange, PTSD, and polytrauma;
- Research has been too slow to be translated into improvements in Veteran care;
- VA is poorly equipped to manage the early translation process of new discoveries into commercial products that can be tested or marketed; and
- VA's academic partners reap a disproportionate share of the rewards of VA/academic partnerships.
Exactly one week later, at a briefing sponsored by Friends of VA Medical Care and Health Research (FOVA), an esteemed panel of VA researchers briefed a packed room of Hill staff on the findings of decades of VA research on chronic pain and opioids. Erin Krebs, MD, MPH, a general internist and part of HSR&D’s Center for Chronic Disease Outcomes Research (CCDOR), spoke about her landmark VA study comparing opioids to stepped care non-opioid therapy for 260 patients with moderate to severe chronic musculoskeletal pain. Recently published in JAMA,1 the study found that opioids were no better than stepped-care for functional outcomes, did slightly worse on pain severity, and caused double the rate of important side effects. She then described a PCORI funded study underway now to compare two alternative approaches for optimizing therapy in patients already on opioids. Matt Bair, MD, MS, another general internist and core investigator with HSR&D's Center for Health Information and Communication (CHIC), described a decade's worth of studies—funded by both VA and the National Institutes of Medicine—which built the evidence for a stepped-care model led by nurses or pharmacists, for optimizing non-opioid therapy. This included the ESCAPE randomized clinical trial that showed a stepped-care intervention combining analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in significant reductions in pain among Veterans with chronic musculoskeletal pain.2 Finally, Sulayman Dib-Hajj, PhD, a neuroscientist from the West Haven VAMC and Yale's Center for Neuroscience and Regeneration Research, described two decades of work unlocking the role of specific sodium channels on pain receptors and their role as possible targets for new pain therapies.
The contrast between the two sessions couldn't have been more striking. VA researchers pointed out the unique capabilities of VA for doing research, including the commitment of Veterans to participating in research as a way to give back to their comrades, the long-term follow-up possible in an integrated system, and the ability of VA to deliver the type of team-based care which is poorly supported by private payers outside VA. They noted how their research had directly contributed to both VA and national CDC guidelinesand to tools for measurement-based care such as brief pain inventories. It was hard to square this meeting with the previous criticism that VA research was more interested in serving the interests of researchers than Veterans.
The nature of Congressional hearings can make it hard to separate broadly held criticisms from comments that reflect momentary frustrations, individual ideology, or basic misunderstanding. Nonetheless, all of us in health services research should seriously consider a number of the concerns that were voiced. First, we need to take more responsibility for translating our research into practice. Real world impact is one of Dr. Ramoni's top three priorities, but the resources of the QUERI program (approximately $20 million annually) are insufficient to ensure that VA research findings are taken up and spread. Since we don't control the policy and resource levers that determine how new practices get taken to scale across the VA healthcare system, we need to engage closely with those regional and national partners that do. Second, we need to build Veteran awareness and support for the breadth of our research. Investigations into health concerns associated with serving in the Gulf War (i.e., fatigue, joint pain) and Vietnam (i.e., Agent Orange) and other issues have been responsive to the mobilization of interested Veteran groups, but other Veterans stand to benefit even more from research that will help deliver more personalized care, slow age-related disability, and improve pain care. Third, we need to continue to demonstrate that we are coordinating with our research partners at NIH and DoD to maximize the value of our investment. Inter-agency collaborations on issues such as suicide, PTSD, and mental health need to be expanded to other areas, including better partnerships to share data. Finally, we need to make the case much more effectively about how much VA and Veterans benefit from our academic research partnerships.
The value of university partnerships has not diminished in the 75 years since General Omar Bradley set the direction of the modern VA after World War II. Acting on the advice of a team of medical experts, including surgeons Paul Magnuson and Michael E. DeBakey, VA forged close academic relationships to further an expanded commitment to research, education, and clinical excellence. Today, these partnerships attract top clinicians and investigators to the VA healthcare system, leverage the research resources of our nation's top research centers, and promote a culture of inquiry that fosters a learning healthcare system and improved care for Veterans.
- Krebs E, Gravely A, Nugent S, et al. Effect of opioid vs. non-opioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain. The SPACE randomized clinical trial. JAMA. 2018;319(9):872-882.
- Bair M, Ang D, Wu J, et al. Evaluation of Stepped Care for Chronic Pain (ESCAPE) in Veterans of the Iraq and Afghanistan conflicts: A randomized clinical trial. JAMA Internal Medicine. May 2015;175(5):682-689.
The 'HSR&D Perspectives' blog is an internal VA blog that focuses on issues that impact the VA HSR&D community. If you have VA Intranet access, you can read the blog here: http://vaww.blog.va.gov/hsrd/ (copy and paste into your browser).