Health Services Research & Development

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ESP Reports in Progress

ESP ReportsESP Topic NominationESP Reports in Progress

The following reports are under development at one of the four ESP sites. If you would like to provide comments about the topic under development, 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.



Strategies for Full System Scale/Spread

Key Questions

What strategies have been used to scale up and spread clinical and administrative practices across healthcare systems, with special attention paid to sites with poor performance or that may be hard to engage in improvement initiatives?

  1. What macro-organizational strategies (ie, at the whole organization or system level) have been used in spread and scale efforts?
    a. What macro-organizational strategies (ie, at the whole organization or system level) were used with sites with poor performance or that may be hard to engage in improvement initiatives?
  2. What micro-organizational strategies (ie, at the individual or group/team level) have been used in spread and scale efforts?
    b. What micro-organizational strategies (ie, at the individual or group/team level) have been used in spread and scale efforts with sites with poor performance or that may be hard to engage in improvement initiatives?

PICOTS

Population(s): Multi-site health care systems

Interventions: n/a

Comparator: n/a

Outcome(s): Uptake of practices across multiple sites within a health care system; ability to produce intended outcomes (eg, cost containment, access to care, coordination among care providers, patient outcomes, etc)

Context: Large health care systems in high-income countries improving clinical care or administrative performance.

General Search Strategy

We will procure literature from 3 main sources:

  1. A systematic search of PubMed and WorldCat databases using terms related to “learning health systems”.
  2. A systematic search of PubMed, WorldCat, Web of Science, and Business Source Complete databases using terms related to “scale and spread”.
  3. Publications in the ART database related to relevant QUERI projects. In addition to using ART database, articles were identified by experts or reference mined.

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Self-management Strategies for Epilepsy

Key Questions

KQ1: For adults with epilepsy, what are the effects of self-management programs on process, clinical outcomes and healthcare utilization?

KQ2:For adults with epilepsy, what are the most commonly employed components of self-management interventions evaluated in comparative studies?

(contingent KQ2b): Which epilepsy self-management intervention components are most effective?

KQ3: What are the identified facilitators and barriers that impact the adoption of self-management programs for adults with epilepsy in large-scale health systems such as the VA?

PICOTS

Population(s): Adults (age ≥ 18 yo) with new or chronic epilepsy. Family members and/or caregivers of those with epilepsy.

Interventions: Self-management (SM), defined as interventions that aim to equip patients with skills to actively participate in and take responsibility for the management of epilepsy in order to function optimally through at least knowledge acquisition and a combination of 1 or more of the following: stimulation of independent sign/symptom monitoring, medication management, enhancing problem-solving and decision-making skills for epilepsy treatment management, safety promotion (eg, driving), and changing health behaviors (including stress management, sleep, substance use).

Comparator: Any, including usual care, attention control, active intervention

Outcome(s):

Clinical: Seizure Rate/frequency/Severity; Quality of Life (QOL); Social function/engagement (eg, days work missed, or validated measure); Psychological symptoms (ie, distress, depressive or anxiety symptoms); Safety outcomes (eg, motor vehicle accidents); Medication toxicity

Process: Epilepsy Self-efficacy and Epilepsy Self-management scales; Medication adherence; Disease knowledge

Utilization: Acute care or emergency department visits; Hospitalization; or Outpatient specialty visits for epilepsy

General Search Strategy

We will conduct a primary search from inception to the current date of MEDLINE® (via PubMed®), PsycINFO, and CINAHL. 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 librarian. We will also search the grey literature specifically by conducting a targeted search in clinicaltrials.gov and through hand-searches of the references from select high-quality systematic reviews and exemplar studies identified during the topic development process and as identified by our stakeholders.

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Guided Imagery, Biofeedback, and Hypnosis

Key Questions

  • KQ1: In which populations has guided imagery been examined, and what is the evidence of effectiveness and harms in each of these populations?
  • KQ2: In which populations has biofeedback been examined, and what is the evidence of effectiveness and harms in each of these populations?
  • KQ3:In which populations has hypnosis been examined, and what is the evidence of effectiveness and harms in each of these populations?

PICOTS

Population(s): Adults (18+) receiving an intervention of interest for any health condition. Children and adolescents are excluded. Exclude studies of healthy volunteers.

Intervention(s): Guided imagery (also “guided meditation,” “yoga nidra,” “mental practice,” “mental rehearsal,” “Katathym-imaginative Psychotherapy,” “autogenic training,” and “integrative restoration”). Studies of guided imagery as part of a complex or multicomponent intervention are excluded.

Biofeedback (also “neurofeedback,” and “neurotherapy”). Studies of biofeedback as part of a complex or multicomponent intervention are excluded.

Hypnosis (also “hypnotherapy”). Studies of hypnosis as part of a complex or multicomponent intervention are excluded.

Comparator: Systematic reviews and meta-analyses of RCTs comparing an intervention of interest to usual care, placebo, or another intervention

Outcome(s): Effect on diagnosis-related symptoms; harms

Setting(s): All health care settings

General Search Strategy

Search strategies will be developed in consultation with a research librarian, and will be peer reviewed by a second research librarian using the instrument for Peer Review of Search Strategies. We will conduct a review of the literature by systematically searching, reviewing, and analyzing the scientific evidence as it pertains to the research questions. To identify relevant systematic reviews/meta-analyses, we will begin by searching Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid MEDLINE, Ovid PsycINFO, CINAHL, Epistomonikos, and Ovid EBM Reviews Cochrane Database of Systematic Reviews (CDSR, DARE, HTA, Cochrane CENTRAL, etc). We will search all available years of publication from database inception (1946 for Ovid MEDLINE®) through March 2018. To identify additional reviews, we will review the bibliographies of relevant reviews of reviews, search the review registry Prospero for completed reviews, and query subject matter experts.

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Adaptive Sports for Veterans with Disabilities

PROSPERO registration: CRD42018105749

Background/Objectives of Review

This report will be used by the Veterans Health Administration national program offices for Physical Medicine and Rehabilitation Services (PM&RS), Prosthetic and Sensory Aids Services (PSAS), Recreation Therapy, and National Veterans Sports Programs and Special Events (NVPS&SE), as well as the offices under Rehabilitation and Prosthetic Services to determine the benefits and harms associated with participation in adaptive sports for Veterans with a disability and identify barriers to and facilitators of participation. This review will inform implementation efforts and enhance efforts to integrate all of the VHA’s national programs for rehabilitation and the Disabled Veterans Adaptive Sports Programs with the goal of advancing Veteran’s access to and the utilization of adaptive sports as part of their ongoing rehabilitation.

Key Questions

KQ 1: What is the effectiveness of participation in adaptive sports programs among individuals with amyotrophic lateral sclerosis (ALS), limb amputation, hearing loss or deafness, multiple sclerosis (MS), post-traumatic stress disorder (PTSD), spinal cord disorder, spinal cord injury (SCI), stroke/cerebrovascular accident (CVA), traumatic brain injury (TBI), or visual impairment or blindness?

KQ 1a: Does the effectiveness vary by frequency/duration of adaptive sport program participation?

KQ 1b: Do particular patient groups (ie, age range, gender, race, time since injury, time involved in adaptive sports, type and/or severity of disability) benefit more than others from adaptive sports participation?

KQ 2: What are the potential harms of participation in adaptive sports programs among individuals with amyotrophic lateral sclerosis (ALS), limb amputation, hearing loss or deafness, multiple sclerosis (MS), post-traumatic stress disorder (PTSD), spinal cord disorder, spinal cord injury (SCI), stroke/cerebrovascular accident (CVA), traumatic brain injury (TBI), or visual impairment or blindness?

KQ 3: What are the known facilitators of and barriers to the participation in adaptive sports programs among individuals with amyotrophic lateral sclerosis (ALS), limb amputation, hearing loss or deafness, multiple sclerosis (MS), post-traumatic stress disorder (PTSD), spinal cord disorder, spinal cord injury (SCI), stroke/cerebrovascular accident (CVA), traumatic brain injury (TBI), or visual impairment or blindness?

PICOTS

Population(s):Individuals age 18 and older with amyotrophic lateral sclerosis (ALS), limb amputation, hearing loss or deafness, multiple sclerosis (MS), post-traumatic stress disorder (PTSD), spinal cord disorder, spinal cord injury (SCI), stroke/cerebrovascular accident (CVA), traumatic brain injury (TBI), or visual impairment or blindness

Interventions: Adaptive sports programs defined for this review as organized programs at any level (eg, community-based, Paralympic) involving 1) a sport that has either been adapted or created specifically for persons with a disability and 2) a group of individuals working together under a coach or program director (eg, a swim program with a coach).

NOTE: We would include studies of Paralympic athletes who might be training on their own but with the intention of competing.

Comparator: Usual care (including community-based rehabilitation), other intervention, or no intervention; studies may be pre- to post-participation in an adaptive sports program, cross-sectional, or trials.

NOTE: We would not include comparisons of different training programs, different wheelchair designs/components, different prosthesis designs, etcetera.

Outcome(s):Effectiveness of adaptive sports among individuals with amyotrophic lateral sclerosis (ALS), limb amputation, hearing loss or deafness, multiple sclerosis (MS), post-traumatic stress disorder (PTSD), spinal cord disorder, spinal cord injury (SCI), stroke/cerebrovascular accident (CVA), traumatic brain injury (TBI), or visual impairment or blindness measured by:

  • health and wellness (eg, management of blood pressure, weight, diabetes [indicated by loss of diagnosis or reduction in medications], pressure sores); smoking cessation; alcohol control (indicated by loss of alcohol dependence)
  • daily functioning (eg, falls, activities of daily living, Bartel index, Functional Independence Measure [FIM])
  • self-esteem
  • perceived competence
  • community reintegration (engagement in other community activities, continuing participation in adaptive sport after the end of the adaptive sport program)
  • participation in social activities
  • employment status
  • mood
  • quality of life
  • health care utilization
  • participation in adaptive sports programs
  • improvement in physical health or PTSD scale scores

Harms of adaptive sports measured by:

  • physical injury
  • worsening of physical disability
  • worsening of physical health or PTSD scale scores
  • costs/burden (system, individual, societal)

Facilitators to adaptive sports

Barriers to adaptive sports

Setting: Community-based adaptive sports programs (to include adaptive sports programs that begin during inpatient rehabilitation and continue to an outpatient/community based phase).

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Cost-effectiveness of Leg Bypass vs Endovascular Therapy for Critical Limb Ischemia

Background/Objectives of Review

The proposed evidence review would be used to provide guidance to VHA vascular surgeons through communication pathways including the Vascular Surgery Specialty Advisory Board and the VISN Chief Surgical Consultants, Chiefs of Surgery, and Section Chiefs of Vascular Surgery at VHA facilities.

Key Questions

KQ1:   Among adults with CLI, what is the cost-effectiveness of leg bypass compared to endovascular procedures including balloon angioplasty, arterial stents, and atherectomy?

KQ2:   Does the cost-effectiveness of leg bypass compared to endovascular procedures for CLI vary by patient population, setting, or time (short vs long-term)?

PICOTS

Population(s): Patients with critical limb ischemia undergoing intervention

Interventions: Endovascular intervention

Comparator: Surgical intervention

Outcome(s): Cost-effectiveness, quality of life, major adverse limb events (MALE), mortality, complications / morbidity, physiologic measures (patency, ABI, flow, etc), utilization measures (length of stay, readmission, repeat procedure).

Setting: All patients will be undergoing intervention – whether as an inpatient or outpatient

General Search Strategy

We will procure literature from a systematic search of PubMed, Medline, and Embase databases using terms related to “limb ischemia”. We will include RCTs, cohort studies, and cost-effectiveness studies.

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Pharmacotherapy for the Treatment of Cannabis Use Disorder: A Systematic Review

PROSPERO registration: CRD42018108064

Background/Objectives of Review

The proposed ESP evidence synthesis review will be used by the Office of Mental Health Services to inform national VHA policy on VA substance use disorder (SUD) treatment. The Center of Excellence in Substance Addiction Treatment and Education (CESATE) would also disseminate the findings to the field to help ensure medication-assisted SUD treatments available to Veterans include the latest evidence on effectiveness and harms. This review would also have the potential to inform future SUD research priorities by identifying gaps in the literature.

Key Questions

KQ1: What are the benefits and harms of pharmacotherapy for cannabis use disorder?

KQ2: Are there known subpopulations for whom currently used pharmacotherapy is most/least effective for cannabis use disorder?

PICOTS

Population(s): Included: Non-pregnant adults and adolescents with known or suspected cannabis use disorder.

Excluded: Children and pregnant adults.

Interventions: Included: Pharmacotherapies identified as a potential treatment for cannabis use disorder with or without adjunctive treatment (eg, medication management; interpersonal therapy; contingency management [or motivational incentives]; CBT [including matrix therapy, relapse prevention]).

Excluded: Pharmacotherapies intended to treat other conditions.

Comparator: Usual care, placebo, or other interventions (comparison groups must receive the same adjunctive treatments)

Outcome(s):

  • Intermediate/Behavioral outcomes;
  • Health and other outcomes;
  • Harms

Setting:

  • Outpatient;
  • Inpatient;
  • Incarceration/detention centers, correctional facilities

General Search Strategy

To identify primary evidence examining pharmacotherapy for cannabis use disorder, we will evaluate the studies included in a 2014 systematic review. In addition, we will conduct a search of Ovid MEDLINE, OvidPsycINFO, and Ovid EBM Reviews Cochrane Database of Systematic Reviews (CDSR, DARE, HTA, Cochrane CENTRAL, etc) for studies published more recently (January 2014 to July 2018). Search strategies will be developed in consultation with a research librarian, and will be peer reviewed by a second research librarian using the instrument for Peer Review of Search Strategies (PRESS).6 We will review the bibliographies of relevant articles and contact experts to identify additional studies. To identify in-progress or unpublished studies, we will search ClinicalTrials.gov, OpenTrials, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP).

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The Effectiveness of Remote Triage

Key Questions

KQ1a: For adults, what are the effects of remote triage on patient satisfaction, health care utilization, case resolution, cost, and patient safety?

KQ1b: What is the impact of remote triage by different modalities (eg, telephone, video, web, SMS)?

KQ2: What are the identified best practices that impact the planning, execution, and evaluation of remote triage for adults seeking clinical care advice in a large-scale health system such as the VA?

KQ3: What are the types of outcomes used to assess the impact of remote triage?

PICOTS

Population(s): KQ1 & KQ2: Adults 18 years of age and older, and their families and caregivers

KQ2 ONLY: Stakeholders involved in the uptake, management, and implementation of remote triage services (eg, nurses, administrators, organizational leadership)

Interventions: Remote triage services as defined by the following: Pertaining to the initial assessment and management of acute, undifferentiated, unscheduled care initiated by patient or family member from a distance focused on a clinical care issue.

Comparator:
KQ1: Usual care/standard of care, waitlist control, other active comparator-focused (eg, in-person care)

KQ 2 and KQ3: No comparator required

Outcome(s):
KQ1: Patient satisfaction, case resolution, patient safety, health care utilization, cost

KQ 2: Best practices for remote triage system (eg, insights into personnel, processes, and technologies needed to stand up a remote triage; implications for what works well and what does not in conducting remote triage)

KQ3: Outcomes used to assess remote triage from papers identified in KQ 1 and KQ2

Study design:
KQ1: EPOC study designs: randomized controlled studies (RCT), non-randomized controlled studies, controlled before-after studies, interrupted time-series studies or repeated measures studies

KQ2: EPOC study designs as well as prospective cohort and case-control if the n is greater than 100, qualitative studies, surveys, systematic reviews, organizational case studies, case series, and guidelines

General Search Strategy

We will conduct a primary search from 2000 to the current date of MEDLINE® (via PubMed®), and CINAHL. 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 librarian.

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Title Interventions to Prevent or Delay Long-term Placement in Nursing Homes for Adults with Physical or Cognitive Impairments

Background/Objectives of Review

This review will be used by the VA Caregiver Support Program, the VA Office of Patient Experience, and the Choose Home Moonshot Workgroup to inform the work of the VA Secretary’s Choose Home Moonshot Initiative. The Moonshot aims to enhance policies and practices nationwide to optimize the ability of Veterans in VA to remain in their own homes if that is their desired setting of care. Specifically, this review will provide a critical appraisal of the available evidence on the effectiveness of various interventions designed to delay nursing home placement among adults with functional or cognitive impairments who are currently living at home.

Key Questions

KQ1: What are the modifiable risk factors that lead to long-term placement in nursing homes?

KQ2: What is the effectiveness of home- and community-based interventions, and group homes or medical foster homes, for preventing or delaying long-term placement in nursing homes?

KQ3: Which characteristics of adults with impairments moderate the effectiveness of home- and community-based interventions, group homes, or medical foster homes in preventing or delaying long-term placement in nursing homes?

PICOTS

Population(s): Adults, Veterans and non-Veterans, with physical or cognitive impairments (due to older age or frailty, dementia, TBI, and/or PTSD)

Interventions: Diverse and complex home- and community-based interventions:

  • Home-based primary care, outpatient geriatric assessment and case management
  • Outpatient or home-based rehabilitation, nursing services, or other medical care
  • Physical activity or exercise (not as part of rehabilitation program)
  • In-home assistance with non-healthcare activities (home aides, home repair, etc)
  • Caregiver interventions
  • Respite care
  • Adult day clinics
  • Community health workers, friendly visits
  • Nutritional programs (Meals on Wheels, congregant dining, grocery delivery, etc)
  • Transportation and mobility services
  • Assistive technologies
  • Alternative housing with range of services (assisted living or group homes, medical foster homes, etc)
  • Financial support and benefits (caregiver stipends, Cash and Counseling, etc)

Comparator: Usual care or other intervention

Outcome(s): Long-term placement in nursing home, function, quality of life, hospitalizations, cost, mortality, harms

General Search Strategy

We will search MEDLINE, Sociological Abstracts, PsycINFO, CINAHL, Embase, PROSPERO, Turning Research Into Practice (TRIP), the Cochrane Database of Systematic Reviews (CDSR), Joanna Briggs Institute Database, Agency for Healthcare Research and Quality Evidence-based Practice Center reports, and VA ESP reports.

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