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VA Health Systems Research

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Reports in Progress

ESP Reports    ESP Topic Nomination    ESP Reports in Progress

The following reports are currently under development. If you would like to provide comments about a particular topic, serve as a peer reviewer for the draft report, or know the timeline for completion, please contact the ESP Coordinating Center.

To review the most up-to-date protocols, please visit the PROSPERO website. Protocol registration numbers for an individual project can be found along with the brief abstract for the project, below.




Automation of Nutrition Delivery

PROSPERO registration number: RD42022347945

Key Questions

KQ1: What are the effects of automating the delivery of oral, enteral, or parenteral nutrition supplements to hospitalized patients on patient and process outcomes?

KQ2: How is automating the delivery of oral, enteral, or parenteral nutrition supplements to hospitalized patients experienced by the staff involved in implementing and delivering it?

PICOTS

Population(s): KQ1: Hospitalized patients - including long-term care, skilled nursing facility residents and end of life patients - at risk of malnutrition (ie, who have difficulty eating or absorbing nutrients through GI tract)

KQ2: Hospital staff involved in automating the delivery oral, enteral, or parenteral nutrition supplements to patients (eg, nurses and nursing assistants, pharmacists, food service, registered dietitians)

Interventions: Automated nutrition delivery of oral, enteral, or parenteral nutrition supplements (ie, medical food supplements) that includes automated notifications to the hospital care team (eg, nurses and nursing assistants, physicians pharmacists, food service, registered dietitians) that nutrition supplements have been ordered/ prescribed and requires responses that the care team has administered nutrition supplements and/or how much the patient actually received (eg, electronic health record alerts, barcode scanning)

Automation is defined as the "creation of a process or application of a technology to deliver hospital-based nutrition to patients minimizing human intervention” (ie, hospital staff provide the thinking on the ordering side (inputs) and the delivery side (outputs) is automated to minimize human touch points).

Automation should include one or both of the following aspects of implementation:

  • Automation of documentation
  • Automation of ordering nutritional supplements, or
  • Automation of the delivery of nutrition supplements

Comparator: KQ1: Any comparator (eg, usual care, active comparator, historical controls)

Outcome(s): KQ1:

Process outcomes:

  • supplements delivered, completion documentation (eg, documentation of supplement administration or reason for non-administration);
  • supplement delivery errors (eg, missed administration, erroneous administration, duplicate intake)

Performance outcomes (eg, time required for supplement administration)

Patient outcomes:

  • Calories consumed, macronutrients consumed (eg, protein)
  • BMI and body weight
  • Fluid intake
  • Wound infections
  • Length of hospital stay
  • Readmission rate
  • Change in nutritional status
  • Post-op ileus (ie, surgery patients)
  • Patient satisfaction

Patient-level harms among patients exposed to automated delivery of nutrition (eg, all-cause mortality, pressure injury, falls, organ damage, aspiration, refeeding syndrome (ie, consuming calories too quickly after starvation), failure to thrive diagnosis, medication-nutrition interactions

KQ2:

Primary purpose of evaluation is to explore the experiences and attitudes of hospital staff (eg, nursing, pharmacy, food service, dietetics) who interact with some aspect of implementing and delivering the automated delivery of nutrition

General Search Strategy

We will conduct a primary search from inception to the current date of MEDLINE (via Ovid), Embase, and CINAHL from inception to January 16, 2022. We will use a combination of MeSH keywords and selected free-text terms to search titles and abstracts. To ensure completeness, search strategies will be developed in consultation with an expert medical librarian. We will hand-search previous systematic reviews conducted on this or a related topic for potential inclusion.

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Nurse Transition to Practice Programs

Key Questions

KQ1: Are transition to practice programs for newly graduated, entry-to-practice registered nurses (RNs) effective for improving organizational, nurse, and patient outcomes?

KQ2: What are the components and implementation characteristics of effective transition to practice programs for newly graduated, entry-to-practice RNs?

PICOTS

Population(s): Newly graduated, entry-to-practice RNs in the first 12 months of employment following graduation and/or licensure for entry to practice

Interventions: Transition to practice or nurse residency programs specifically designed for newly graduated, entry-to-practice RNs to provide support or preceptorship during the first 12 months of employment following graduation and/or licensure for entry to practice

Comparator: Any comparator (eg, usual care, active comparator, historical controls)

Outcome(s):

Key question 1:

  • Organizational outcomes (eg, retention/attrition, quality of care),
  • Nurse outcomes (eg, confidence, competence, practice-readiness, satisfaction),
  • Patient outcomes (eg, patient satisfaction, adverse events),

Key question 2:

  • Components (eg, preceptorships, simulations),
  • Implementation characteristics (eg, duration, recruitment strategies, settings, utilization, uptake, barriers/facilitators, collaboration with academic partners)

Setting: Any healthcare setting; programs implemented in countries listed on the 2022 Organization for Economic Co-operation and Development to approximate US healthcare delivery context.

General Search Strategy

We will conduct searches from 1/1/10 to the current date of PubMed/MEDLINE and CINAHL Plus. We will use a combination of MeSH keywords and selected free-text terms to search titles and abstracts (eg, “Education, Nursing, Graduate”, “graduate nurse transition”, “transition to practice”). To ensure completeness, search strategies will be developed in consultation with an expert medical librarian. We will hand search references from previous, relevant systematic reviews for potential inclusion.

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Extended Reality for Chronic Pain

PROSPERO registration number: CRD42023439903

Background

This evidence review of extended reality (XR; including virtual reality [VR], mixed reality, and augmented reality) approaches for addressing chronic pain will be used to inform clinical guidance on use of XR to treat pain within the VA, as well as future research priorities targeted at evidence gaps in this area of work. Chronic pain is common in Veterans, and the prevalence of severe pain is higher in Veterans than in members of the general population. XR approaches may be promising non-pharmacological treatment options for chronic pain. VHA Extended Reality Network has launched several pilots of VR interventions to address pain, including one most recently to treat chronic low back pain. VA HSR&D and PMOP are collaborating with the Network on current and future efforts to implement XR treatments and address evidence gaps.

Key Questions

KQ1: For adults, what are the benefits and harms of extended reality (XR) interventions for treating chronic pain?

KQ2: For adults, what are the benefits and harms of XR interventions for preventing the development of chronic pain?

PICOTS

Population(s):

KQ1: Adults (≥18 years) with chronic pain:

condition that has chronic pain as a major symptom (eg, arthritis, fibromyalgia, phantom limb pain, diabetic neuropathy) AND/OR assessed pain of ≥ 90 days

KQ2: Adults (≥18 years) with pain

Interventions: Extended reality (ie, augmented, mixed or fully immersive virtual reality) treatments with a primary aim of treating or preventing chronic pain

Comparator: Any

Outcome(s):

  • Pain-related functioning or interference
  • Pain intensity/severity
  • Pain global change
  • Pain catastrophizing
  • Quality of life
  • Adverse events
  • Opioid use
  • Completion of medical treatments or adherence
  • Physical performance

Setting:

KQ1: Non-acute care settings (eg, outpatient clinic, home)

KQ2: Any

General Search Strategy

We will search MEDLINE, Embase, CINHAL, PsycINFO, and Scopus databases, from inception to current.

We will perform citation searching of relevant systematic reviews identified via the searches described above, as well as additional searches of AHRQ EPC and VA ESP reports. We also plan to perform searches of grey literature, including clinical trial registries.

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Radiation Therapy for Benign Conditions

Key Questions

What are the benefits and harms of low-dose radiation therapy for the treatment or prevention of benign hyperproliferative and degenerative skin/epithelial, and musculoskeletal disorders such as keloid scars, hidradenitis suppurativa, Dupuytren’s contracture, Ledderhose disease, Peyronie’s disease, plantar fasciitis, heterotopic ossification, pterygium, or osteoarthritis in adults?

PICOTS

Population(s): Adults ≥18 years of age with keloid scars, hidradenitis suppurativa, Dupuytren’s contracture, Ledderhose disease, Peyronie’s disease, plantar fasciitis, heterotopic ossification, pterygium or osteoarthritis (treatment, recurrence, or prevention).

  • Exclude patients with cancer, central nervous system conditions, nonmalignant tumors of in the head / neck, brain, neurofibromatosis I and II, pre-cancerous conditions of the skin (e.g., Bowen’s disease).
  • Exclude patients receiving re-irradiation (of the same anatomic location).
  • Photon, electron (beta particle), alpha particle therapy, or other-hadrons (positively charged particles).
  • <60 Gy
  • Only include brachytherapy for pterygium.
  • Exclude: Non-ionizing radiation and re-irradiation.

Comparator: Sham radiation therapy, alternative treatments that do not include radiation, no treatment.

Outcome(s):

  • Disease related symptoms
    • g., pain, stiffness, ambulatory status
    • Appearance of the tissue (Keloid)
    • Recurrence of lesion
    • Control of symptoms
  • General quality of life
  • Physical functioning
  • Patient satisfaction / experience of care
    • Local (short term) radiation side effects
    • Skin irritation, discoloration, scarring of tissue
    • Edema
    • Fatigue
    • Nausea
    • Alopecia
    • Anemia
    • Atrophy
  • Burden related to accessing treatment
    • Wait time
    • Distance patient traveled
    • Travel costs

Setting: Any

General Search Strategy

We will conduct literature searches of the bibliographic databases including PubMed (Medline, EMBASE and clinicaltrials.gov (http://clinicaltrials.gov) by utilizing keywords and subject headings for each disease of interest (i.e., keloids, heterotopic ossifications) and radiation therapy.

There will be no restrictions to language of publication for searches.

We will review the list of references in identified systematic reviews.

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Classification of Cancer Cachexia

PROSPERO registration number: CRD42023458540

Key Questions

KQ1:
1a. What cancer cachexia classification systems have been described/what criteria have been used?
1b. What are their performance characteristics?

KQ2: What are the short- and long-term outcomes for patients following cachexia classification with the tools identified in KQ1?

PICOTS

Population(s): This review will focus on adults with any type of cancer at risk for cachexia or with cachexia. We will exclude studies focusing on non-cancer populations, those conducted in pediatric populations, and those using non-human subjects.

Interventions/exposures: For KQ1, the exposures of interest will include cancer cachexia diagnostic strategies, screening, and classification/severity scoring tools (including modified tools, algorithms) (herein referred to as classification strategies).

For KQ2, the exposure of interest in cachexia stage. We will exclude studies that do not define the classification strategy used for cachexia.

Comparator(s): Comparators for KQ1 may include a reference standard for classification, an alternate classification strategy, or no comparator. Comparators for KQ2 may include other cachexia stages or those without cachexia.

Outcome(s):For KQ1, outcomes will include parameter for classification and data on performance measures of the identified classification strategies (eg, diagnostic accuracy, predicative ability, etc).

For KQ2, outcomes of interest include clinical and patient-important outcomes (eg, treatment response, overall survival, nutritional outcomes, functionality, quality of life):

  • Survival (overall, cancer specific, etc)
  • Recurrence
  • Cachexia symptom burden/severity (anorexia, fatigue, change in taste, etc)
  • QOL
  • Functional levels (ECOG, KPS, ADLs, measures of mobility, exercise tolerance, etc)
  • Hospitalizations
  • Cancer treatment compliance/tolerance
  • Feeding tube placement
  • Cachexia progression
  • Cancer progression
  • Need for TPN
  • Response to nutritional supplementation
  • Development of malnutrition
  • Long-term steroid use
  • Other medication use (eg, orexigenics, antipsychotics)
  • Physical activity/exercise recommendation and compliance

Setting: We will not place any restrictions on the timing or setting of studies.

General Search Strategy

We will conduct literature searches of the bibliographic databases including PubMed (Medline), EMBASE, Cochrane and clinicaltrials.gov (http://clinicaltrials.gov) by utilizing keywords and subject headings relating to cancer cachexia, and severity assessment and diagnostic tools.

No restrictions will be placed on language or date of publication.

We will review the list of references in identified systematic reviews.

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Occurrence of Psychiatric Conditions or Symptoms after Military Service-related Environmental and Chemical Toxic Exposures

Background/Objectives of Review

An evidence map on the association between toxic exposures during military service and mental, behavioral, and neuropsychiatric health issues (ie., psychiatric conditions or symptoms). The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act expands and extends VA health care eligibility for Veterans with conditions presumed to be caused by toxic exposure that occurred during military service. An evidence map on this topic will be used to assist clinical teams in providing evidence-informed care to Veterans with psychiatric concerns that arise during toxic exposure screenings and to develop national guidance for approaches to screening, assessment, and treatment related to these concerns.

Key Questions

KQ1: For which military service-related environmental and chemical toxic exposures has the co-occurrence of psychiatric conditions or symptoms been evaluated?

KQ2: What is the prevalence, incidence, or association of co-occurring psychiatric conditions or symptoms among individuals with a history of military-service related environmental and/or chemical toxic exposures?

PICOTS

Population(s): Active-duty military personnel, national guard, reservists, or Veterans from the US or other countries.

For studies with mixed populations, 80% (and at least 100 individuals in total) of the analytic sample must be compromised of individuals meeting the above definition.

Intervention(s)/exposure(s): Exposure to environmental (eg, burn pits, radiation) and/or chemical (eg, asbestos, agent orange) toxins during military service inclusive of:

  • Exposures that may have occurred during deployment or when not deployed
  • Exposures that may be self-reported or objectively verified

Comparator(s): No history of toxic exposure or no comparator

Outcome(s):Psychiatric symptoms and conditions, inclusive of related diagnoses (eg, MDD, GAD, PTSD, Mild or Major Neurocognitive Disorder, substance use disorder) and symptoms (eg, executive functioning, difficulty concentrating, memory, processing speed, suicidal behavior/ideation, sleep disturbance, aggression)

General Search Strategy

We will conduct a primary search from 1946 to July 27th 2023 of MEDLINE (via Ovid), Embase (via Elsevier), APA PsycINFO (via Ovid), and PTSDpubs (via ProQuest). We will use a combination of MeSH keywords and selected free-text terms to search titles and abstracts. To ensure completeness, search strategies will be developed in consultation with an expert medical librarian and peer-reviewed by another librarian. We will hand search selected systematic reviews conducted on this or related topics for potential inclusion.

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Post-discharge Contacts

PROSPERO registration number: CRD42023465675

Objectives of Review

An evidence review would inform efforts to standardize the way post-discharge follow-up calls are conducted across VHA facilities, including development of a standard operating procedure and a national documentation template.

Key Questions

KQ1a: Among adults with acute medical hospital admissions, what are the effects of post-discharge contacts on hospital readmission, emergency care use, and patient satisfaction?

KQ1b: Do the effects of post-discharge calls for acute medical hospital admissions vary by intervention characteristics (ie, mode of contact; clinical staff initiating the contact; timing of the contact; assessments used during contact; content of the contact)?

KQ2a: Among adults with acute psychiatric hospital admissions, what are the effects of post-discharge contacts on hospital readmission, emergency care use, and patient satisfaction?

KQ2b: Do the effects of post-discharge calls for acute psychiatric hospital admissions vary by intervention characteristics (ie, mode of contacted; clinical staff initiating the contact; timing of the contact; assessments used during contact)?

PICOTS

Population(s):

KQ1: Adults (≥18 years of age) with an acute medical hospital admission

KQ2: Adults (≥18 years of age) with acute psychiatric hospital admission

If populations are comprised of children and adults and does not include an adult-only subgroup, studies will be included if they have 80% or more adults in the included sample.

Intervention(s)/exposure(s): Post-discharge contact is defined as a bidirectional contact (eg, telephone, video, secure messaging system) from a non-specialist clinical service provider to an adult discharged from inpatient medical or psychiatric hospital that occurs up to 7 days from discharge from a hospitalization and prior to resumption of longitudinal primary care.

A post-discharge contact is intended to improve the post-acute transition from hospital to home and include at least one of the following components:

  1. medication reconciliation (eg, did patients fill new medications, understand directions about change in dosages, start new medications, and assessing tolerability of any new medications);
  2. coordination of services (eg, do patients understand planned follow up appointments including referrals to new specialists, have any ordered in-home services or ordered durable medical equipment arrived or been scheduled, connections to community-based organizations made);
  3. monitoring (eg, are patients symptoms continuing to improve post-hospitalization, lab monitoring, anticipatory guidance on when to reach out to providers on symptoms changes);
  4. psychoeducation (eg, do patients/care supports understand and act on other discharge instructions such as wound care, daily weights, dietary changes)

Comparator(s):

  • Usual care/standard of care, waitlist control
  • Other active comparator (eg, in-person care)

Outcome(s):

  • 30-day hospital readmission
  • 30-day emergency care use
  • Patient satisfaction

Setting: Initiated in the inpatient or outpatient setting, as long as the intent is to provide a post-discharge check-in prior to resumption of longitudinal primary care AND there is at least one contact made after the patient is discharged.

General Search Strategy

We will conduct a primary search from inception to the current date of MEDLINE (via Ovid), Embase, and CINAHL from inception to May 25th, 2023. We will use a combination of MeSH keywords and selected free-text terms to search titles and abstracts. To ensure completeness, search strategies will be developed in consultation with an expert medical librarian. We will hand search previous systematic reviews conducted on this or a related topic for potential inclusion.

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Clinical and At-Home Resources for PTSD

PROSPERO registration number: CRD42023471333

Key Questions

KQ1: Are internet-based and mobile interventions with asynchronous therapist-guided or self-guided content and resources designed to improve PTSD symptom severity and/or self-management effective for improving PTSD symptoms and other mental health symptoms among adults with a diagnosis of PTSD?

KQ2: Are internet-based and mobile interventions with asynchronous therapist-guided or self-guided content and resources designed to enhance coping and symptom management skills for family members and caregivers of adults with PTSD effective for improving stress, mental health symptoms, and coping skills?

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An Evidence Map of Women Veterans’ Health Literature (2016–2023)

Key Question

What is the scope and breadth of the literature on women Veteran’s health published since 2015?

Participants/population: Individuals who identify as women or who have female reproductive or sexual anatomy

AND, who have served in the armed forces including national guard and reserves

(Note: Women Veterans (WV) must comprise >75% of study population OR study must report results separately for WV as sub-group analysis or otherwise report results separately for women; total n must be at least 50 unless is a qualitative study or methods development)

OR, health care team members who provide care to women Veterans if focus of article is on provision of care to women Veteran population

Intervention(s)/exposure(s): Any or none

Comparator(s): Any or none

Outcome(s): Any

Context: Health care and health conditions relevant to women Veterans, including social determinants of health

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Shared Decision-Making for Lung Cancer Screening

PROSPERO registration number: CRD42024511257

Key Questions

KQ1: What communication strategies, tools, and/or approaches used for shared decision making (SDM) in lung cancer screening are reported in the literature?

KQ2: What is the effectiveness and comparative effectiveness of communication strategies, tools, and or approaches used to enhance SDM for lung cancer screening?

b. Does effectiveness vary by patient (i) or clinical setting (ii) characteristics:

i. ie, age, race/ethnicity, comorbidities, current smoking status, socioeconomic status (SES)/education, residency: geographic region, rural/urban
ii. Primary care, smoking cessation, prevention clinics, public forums

KQ3: What are the harms of the communication strategies, tools, and or approaches used to enhance SDM for lung cancer screening?

KQ4: What are the barriers and facilitators of implementing different communication strategies, tools, and/or approaches for lung cancer screening SDM?

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Adult ADHD Among Veterans

Key Questions

KQ1: Among adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) and prescribed psychostimulant medications, what is the incidence of misuse of the prescribed medications, the incidence of diversion of the prescribed medications, and the incidence of substance use disorders (SUD) in this population?

KQ2: Among adults diagnosed with ADHD with a co-occurring substance use disorder (SUD), what are the benefits and harms of non-stimulant ADHD pharmacological and/or nonpharmacological treatment of ADHD compared to ADHD psychostimulant medications?

Participants/population:

KQ1: Adults and adolescents (age 12 and older at the time of study enrollment) diagnosed with ADHD using DSM-IV, IV-TR, V, V-TR or comparable criteria (eg, ICD codes, validated instruments) who have been prescribed psychostimulant medications for ADHD and are without a history or current diagnosis of ADHD medication misuse or diversion, or SUD.

KQ2: Adults 18+ diagnosed with ADHD using DSM-IV, IV-TR, V, V-TR or comparable criteria (eg, ICD codes, validated instruments) with a history or current diagnosis of a SUD.

Intervention(s)/exposure(s): Prescribed psychostimulant medications for ADHD, including short- and long-acting types

Comparator(s):

KQ1: None

KQ2: ADHD psychostimulant medication use alone will be compared to non-psychostimulant pharmacological ADHD medication, psychotherapeutic interventions intended to improve ADHD management skills and/or symptoms (eg, behavior management interventions like cognitive behavioral therapy, cognitive training interventions such as attention training or neurofeedback, or psychoeducation) and/or treatment as usual (including those that compare different doses of stimulants) or no treatment.

Exclude: Nonpharmacologic interventions which are not conducted by trained clinicians.

Context:

KQ1: Studies conducted in any community setting.

KQ2: Studies conducted in outpatient, residential, or community settings, and will exclude inpatient and incarcerated populations.

Outcome(s):

KQ1: ADHD medication misuse or diversion in adulthood (including poisoning/overdose) or development of substance use disorder/dependence/psychosis/abuse diagnosis in adulthood.

Exclude: Studies that do not assess any other substance beside tobacco/nicotine or caffeine and studies not examining outcomes in adulthood.

KQ2: Change in ADHD symptoms/severity or functional ability or impairment, SUD relapse/misuse/diversion, treatment adherence (SUD and ADHD), side effects, mortality, QOL and satisfaction, and other mental health diagnoses (including change in severity or symptoms)

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Moral Injury Evidence Assist

Key Questions

KQ1: What are the characteristics of published research studies on moral injury in adults?

KQ2: How has published literature on moral injury changed over time?

KQ3: How many studies include moral injury as an outcome measure?

Population: KQ1&KQ2: Adults with or at risk for moral injury; KQ3: Any

Intervention: Any or none

Comparator: Any or none

Outcomes: KQ1&KQ2: Any; KQ3: Moral injury

Study Design: KQ1&KQ3: Research studies; KQ2: Any publication type

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