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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.




Screening for Male Osteoporosis

Key Questions

KQ1: Among males, is there a clinical risk tool (eg, FRAX) that identify patients at highest risk of osteoporosis or major osteoporotic fracture?

KQ2: Among male Veterans, is there a combination of risk factors that identify patients at highest risk of osteoporosis or major osteoporotic fracture?

KQ3: What systems level interventions improve uptake of osteoporosis screening?

PICOTS

Populations:
KQ 1: Adult men, KQ 2: Adult male Veterans, KQ 3: Health care providers, adult patients, health system administrators and/or staff.

In studies that recruit populations with and without facture histories, 80% of recruited study population should have no prior identified low-trauma fracture.

For studies with mixed populations of men and women, we will include them if they conduct a subgroup analysis of men only.

Interventions:
KQ 1: Clinical risk assessment or fracture risk predations tools (eg, FRAX, GARVAN FRC, Q fracture, fracture risk calculator, Osteoporosis Screening tool [OST], male osteoporosis screening tool [MOST], Male Osteoporosis Risk Estimation Score [MORES]); combination of assessment tools and screening tests (eg, dual-energy x-ray absorptiometry-DXA)

KQ 2: Risk factor for osteoporosis (eg, medication use, smoking, body mass index) and clinical risk assessment or fracture risk predations tools.

KQ 3: System-level approaches targeting provider behaviors or systems operations to optimize uptake of osteoporosis screening (eg, clinical reminder systems; bone health clinics; provider education; tailored and/or bi-directional patient education such as IVR assessing individual risk scores; remote consultation; nurse/physician/pharmacist led interventions; clinician incentives, academic detailing; patient self-referral system)

Comparators:
KQ 1 & KQ 2: other risk assessment tools, bone mineral density testing via validated approach (eg, dual-energy x-ray absorptiometry-DXA)

KQ 3: usual care, other system-level approached, patient-focused interventions

Outcomes:
KQ 1 & KQ 2: fracture rates; bone mineral density

KQ 3: fracture rates, screening rates

Setting: Outpatient general medical settings (eg, geriatrics, family medicine, general internal medicine, integrative medicine, urgent care, emergency departments) or inpatient health care settings

General Search Strategy

We will conduct a primary search from inception to the current date of MEDLINE® (via PubMed®), Embase, 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 hand search key references for relevant citations that may not be captured by our database search.

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Gulf War Illness – A Systematic Review of Therapeutic Interventions and Management Strategies

Background/Objectives of Review

The Gulf War Research Program would use the findings of this evidence review to inform the planning for a state-of-the-art meeting on Gulf War Research and to provide guidance for ORD funding priorities in Gulf War research. The War Related Illness and Injury Study Center would utilize the summary to communicate to providers, patients, and other stakeholders about evidence-based treatments in its education and clinical care activities.

Key Questions

KQ1: Evidence on effectiveness/harms: What are the benefits and harms of pharmacological and non-pharmacological interventions and management strategies for Veterans with GWI?

KQ2: Evidence about subgroups: Do the effectiveness or harms of the interventions/strategies differ among subgroups of Veterans with GWI, such as female Veterans or cases defined by specific criteria, in comparison with Veterans with GWI overall?

KQ3: Emerging research: What interventions for GWI have been examined in

  1. a) noncomparative studies only?
  2. b) ongoing/unpublished trials or cohort studies?

PICOTS

Population(s): We will include studies of Veterans with GWI who were deployed to the Persian Gulf region between Aug 2, 1990 - Nov 1991. We will include studies of international veteran populations (but limit to English-language publications). We will include studies of civilian contractors present during the conflict, if available. We will also include studies of Veterans with GWI whose deployment status is unclear (eg, if diagnosis was made according to CDC/Fukuda 1998 criteria).

Interventions: Pharmacological and nonpharmacological interventions or management strategies for Gulf War Illness

Comparator: Comparators include another active intervention, placebo, or usual care.

Outcome(s): Outcomes of interest are the 3 symptom domains that occur in both the CDC and Kansas case definitions: cognitive function, fatigue, and pain.

Other outcomes of interest:

  • Additional symptom domains used in the Kansas case definition (sleep, mood, musculoskeletal, gastrointestinal, respiratory, dermatological)
  • Global outcomes (eg, QOL and measures of function)
  • PTSD
  • Adverse effects of treatment

General Search Strategy

We will conduct a primary review of the literature by systematically searching, reviewing, and analyzing the scientific evidence as it pertains to the research questions. To identify relevant articles, we will search Ovid MEDLINE, Ovid PsycINFO, Ovid EBM Reviews (Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), CINAHL, and AMED: Allied and Complementary Medicine Database. 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.5 The search strategy will include terms to identify Veterans from the Gulf War era (eg, Desert Shield, Desert Storm, Kuwait War, Operation GRANBY) combined with past and present terms to identifying Gulf War Illness, (eg, chronic multisymptom illness, chronic fatigue, Gulf War Syndrome). An English language limit will be used, however no limits on publication status nor study design will be imposed. To identify in-progress or unpublished studies, we will search ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We will review the bibliographies of relevant articles and contact experts to identify additional studies.

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Models and Tools for Care Coordination Implementation

Background/Objectives of Review

The Coordinated Care and Integrated Case Management (CC&ICM) initiative has implemented several tools for identification and stratification of Veterans who may benefit from various levels of care coordination services. They are currently piloting these tools at 12 VHA sites, and have plans to evaluate these tools in the near future. CC&ICM would like to better understand the evidence on other tools to evaluate and guide implementation of care coordination models, and which types of models have been effective (and in which health care setting). Results from this review will be used by CC&ICM to help guide selection and implementation of VA care coordination models and tools.

Key Questions

For community-dwelling adults with ambulatory care sensitive conditions (at higher risk of having repeat hospitalization of emergency department [ED] visits):

KQ1: What are the key characteristics of care coordination models (of varying levels) that aim to reduce hospitalization or ED visits?

KQ2: What is the effect of implementing these care coordination models on hospitalizations, ED visits, and patient experience (eg, CAHPS)?

KQ3: What are the characteristics of settings in which effective models have been implemented?

KQ4: Among effective models, which approaches/tools have been used to:

  1. Measure patient trust or working alliance?
  2. Measure team integration?
  3. Improve communication between patients and providers?

PICOTS

Population(s): Community-dwelling adults, Veterans and non-Veterans

Interventions: Models of care coordination that involve outpatient care

Comparator: Any

Outcome(s): Hospitalization, ED visits, patient experience

Setting: Outpatient (including clinics, home and community settings)

General Search Strategy

MEDLINE, Embase, CINAHL, Cochrane Database, AHRQ Evidence-based Practice Center, and VA ESP reports

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Robot-assisted Procedures in General Surgery: Cholecystectomy, Inguinal and Ventral Hernia Repairs

Key Questions

KQ1: What is the clinical effectiveness of robotic-assisted surgery compared to open surgery or conventional laparoscopic surgery for cholecystectomy or hernia surgery?

KQ2: What is the cost-effectiveness of robotic-assisted surgery compared to open surgery or conventional laparoscopic surgery for cholecystectomy or hernia surgery?

PICOTS

Population(s): Adults undergoing general surgery including cholecystectomy for benign disease, inguinal hernias and ventral hernias (<10 cm, >=10 cm, complex repairs).

Interventions: Robotic-assisted surgery

Comparator: Open surgery or conventional laparoscopic surgery

Outcome(s): Cholecystectomy: Perioperative (length of stay, complications, estimated blood loss, operating room time); short term (readmission, reintervention, hernia occurrence, pain, narcotic use, return to work), long term (hernia occurrence, quality of life); and cost.

Inguinal and ventral hernia: Perioperative (length of stay, complications, estimated blood loss, operating room time); short term (readmission, reintervention, hernia recurrence, pain, narcotic use, return to work), long term (hernia recurrence, pain, quality of life); and cost.

General Search Strategy

We conducted broad searches using terms relating to “robotic surgery” or “cholecystectomy” or “incisional hernia surgery” or “inguinal hernia surgery”. For cholecystectomy, we searched PubMed, Cochrane, and Embase from inception through 8/21/19; For inguinal and incisional hernias, we search Medline, PubMed, Embase, and Cochrane from inception to 9/3/19.

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Transformational Coaching

Key Questions

KQ 1a: What are the effects of transformational coaching on health care team improvement and change efforts as compared to no transformational coaching on goal attainment (e.g., #QI projects reaching completion), adoption of QI strategies (e.g., increased appropriateness of documentation of screening), and change in team member knowledge?

KQ 1b: What are the types of outcomes used to assess the effect of transformational coaching in the existing literature?

KQ 2: What are the identified barriers and facilitators that impact the implementation and adoption of transformational coaching in a large health care system such as the VA?

PICOTS

Population(s): KQ 1: Established interdisciplinary health care delivery teams (including clinic or unit-level)

KQ 2: Any member of an interdisciplinary health-care delivery team which received transformational coaching (including clinic or unit-level)

Interventions: KQ 1a, 1b, and KQ 2:

1) clinical content-agnostic (not necessarily an expert in clinical topic/intervention)

2) coach is external to target of coaching (ie, not a member of health care delivery team being coached)

3) aims to catalyze and/or build capacity for sustained change and improvement, through activities such as assisting with goal setting, goal attainment, connection to system level resources for change, and/or improving efficiency and team dynamics around change/improvement processes

Comparator: KQ 1a & b: Any

KQ 2: NA

Outcome(s): KQ 1a: Must have at least one of the following:

1) Goal Attainment (ie, #QI projects reaching completion)

2) Adoption of QI strategies (ie, increased appropriateness of documentation of screening)

3) Change in team member knowledge

4) Team member self-efficacy

KQ 1b: Any

KQ 2: Evaluations of influencers or determinants of implementation and adoption of transformational coaching

Setting: Any health care system setting

General Search Strategy

We will conduct a primary search from inception to the current date of MEDLINE® (via Ovid), Embase (via Elsevier), and CINAHL complete (via EBSCO). 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 hand search key references for relevant citations that may not be captured by our database search. When search terms are identified after the execution of the literature search, the terms will be searched independently and any relevant references will be added to the database.

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Biomarkers and Diagnostic Tools for Gulf War Illness – A Systematic Review

Background/Objectives of Review

To inform diagnosis and/or treatment of GWI in the VHA by assisting in the planning for a state-of-the-art meeting on Gulf War Research and providing guidance for ORD funding priorities in Gulf War research.

Key Questions

KQ1: Which diagnostic tests (or test combinations) are candidates for distinguishing individuals diagnosed with GWI from individuals without GWI?

KQ2: Which biomarkers have been examined for their potential association with GWI, and which among them have been shown to be associated with GWI?

KQ3: Which ongoing or unpublished research studies examine diagnostic tests or biomarkers for potential association with GWI?

PICOTS

Population(s): Case definition: Veterans and civilian contractors who were deployed to the Persian Gulf region between Aug 2, 1990 and Nov 1991, and diagnosed with GWI (ie, according to either CDC/Fukuda 1998 or Kansas criteria, or other criteria). Include studies of international Veteran populations if they use any definition of Gulf War Illness (limited to English-language publications).

Comparator populations: Studies with any comparator populations (without GWI) will be included, but will be stratified by importance during the evidence synthesis phase, from most to least informative:

  • Veterans who were deployed elsewhere (other than Persian Gulf) during the Gulf War.
  • Gulf War-deployed Veterans
  • Non-deployed Gulf War era Veterans
  • Civilians with other health conditions/conditions with similar symptomology to GWI (e.g., chronic fatigue syndrome, neurodegenerative disorders, musculoskeletal problems)
  • Healthy controls

Exclude: children and birth outcomes of Gulf War Veterans.

Interventions: Measures of any of the following categories of biological functions/systems that are potential loci of dysfunction:

  • Genes
  • Immune activation/inflammation
  • Neurodegeneration
  • Autonomic nervous system
  • Endocrine system
  • Energy metabolism
  • General brain activity
  • Other

Exclude: Psychological/psychiatric assessments that do not include biological measurements (eg, questionnaires)

Comparator:
KQ1: Compares a test’s classification of GWI diagnosis with a reference standard’s classification (diagnosis of GWI according to Kansas or CDC/Fukuda 1998 criteria).

KQ 2&3: Compares Veterans clinically diagnosed with GWI vs. any comparator group (see comparator populations above)

Outcome(s): KQ1: Measures of diagnostic accuracy:

  • Sensitivity and specificity
  • Positive and negative predicative values (PPV, NPV)
  • Likelihood ratio
  • The area under the ROC curve (AUC)

KQ 2: Measure of association between biological measurement and GWI

KQ3: Study objectives, status, outcome measures, and available findings.

General Search Strategy

We will conduct a primary review of the literature by systematically searching, reviewing, and analyzing the scientific evidence as it pertains to the research questions. To identify relevant articles, we will search Ovid MEDLINE, Ovid PsycINFO, Ovid EBM Reviews (Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials), CINAHL, and AMED: Allied and Complementary Medicine Database. 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. The search strategy will include terms to identify Veterans from the Gulf War era (eg, Desert Shield, Desert Storm, Kuwait War, Operation GRANBY) combined with past and present terms to identify GWI, (eg, chronic multisymptom illness, chronic fatigue, Gulf War Syndrome). An English language limit will be used, however no limits on publication status nor study design will be imposed. To identify in-progress or unpublished studies, we will search ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We will review the bibliographies of relevant articles and contact experts to identify additional studies.

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Chronic Pain in Veterans and Servicemembers with a History of Mild Traumatic Brain Injury: A Systematic Review

Background/Objectives of Review

The findings of this evidence review will bring to the attention of the VHA which metrics and therapies have been validated for this population. If no validated metrics or therapies can be found in the literature, specific gaps will be highlighted for future investigation.

Key Questions

KQ1: What is the prevalence of chronic pain in US Veterans or Servicemembers with a history of mTBI?

  1. What are the most common types of chronic pain in US Veterans or Servicemembers with a history of mTBI?
  2. Do the prevalence or types of chronic pain experienced by US Veterans or Servicemembers with a history of mTBI differ by mTBI etiology?
  3. How do estimates of the prevalence of chronic pain and mTBI in US Veterans or Servicemembers differ according to pain measurement methods or definitions?

KQ2: What is the risk of suicide in US Veterans or Servicemembers with chronic pain and a history of mTBI?

  1. How does the prevalence of suicide-related outcomes in US Veterans or Servicemembers with a history of mTBI and chronic pain compare to US Veterans or Servicemembers with no mTBI history and/or no chronic pain?
  2. How does the prevalence of suicide-related outcomes in US Veterans or Servicemembers with chronic pain and history of mTBI compare to civilians with chronic pain and history of mTBI?
  3. How does the prevalence of suicide-related outcomes in US Veterans or Servicemembers with chronic pain and a history of mTBI vary depending on mTBI etiology?
  4. How does the prevalence of suicide-related outcomes in US Veterans or Servicemembers with chronic pain and a history of mTBI vary depending on prescription opioid use or opioid use disorder?

KQ3: What are the benefits and harms of interventions to treat chronic pain in Veterans or Servicemembers with a history of mTBI?

  1. Do the benefits or harms differ by mTBI etiology, type of chronic pain, mental health comorbidities, intervention setting, and demographics?
  2. How is pain assessed in clinical trials for comorbid chronic pain and history of mTBI in Veterans and Servicemembers?

PICOTS

Population(s): Veterans or Servicemembers with chronic pain and a history of mild TBI (Limited to US population for KQs 1 & 2, but not KQ3)

Interventions: KQ3: Pharmacologic, nonpharmacologic, and complementary and integrative health interventions

Comparator:
KQ1 & 2: mTBI injury type, direct comparisons to those with no mTBI history and/or no chronic pain, direct comparisons of US Veterans or Servicemembers and civilians

KQ3: Placebo, active comparator, usual care, wait-list control, pre-post

Outcome(s): KQ1: Prevalence, demographics, chronic pain types

KQ2: Suicide-related outcomes (including suicide, suicidal ideation/intent/plan, and suicidal self-directed harm)

KQ3: Benefits: Intermediate and patient outcomes, utilization (eg, reduced pain, mental health diagnosis/symptoms, opioid use; better QOL, functioning, treatment adherence)

Harms: AEs, SAEs, withdrawals due to AEs

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 (PRESS). 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 studies, we will search the following databases: Ovid Medline; Ovid EBM Reviews: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews; Ovid PsycINFO; CINAHL; Scopus (conference abstracts only); and Epistemonikos. To identify ongoing studies, we will also search Clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP).

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The Effect of Medical Scribes in Cardiology, Orthopedic, and Emergency Departments: a Systematic Review

Background/Objectives of Review

Little is known about the impact of using medical scribes in specialty care or emergency departments within the VA. Section 507 of the 2018 VA MISSION Act, Medical Scribes Pilot, mandates a 2-year medical scribe pilot in the VA in specialty care and emergency department settings. The pilot involves hiring 40 medical scribes, half as VA employees and half as contracted employees. This pilot will begin in Quarter 2 of FY20 and will evaluate the impact of medical scribes on provider efficiency, patient volume, and patient satisfaction. A systematic review examining the effect of medical scribes in cardiology, orthopedic, or emergency department clinics would supplement findings from this pilot to inform future use of medical scribes in the VA.

The Section 507 Committee will use the findings of this evidence review alongside findings from the medical scribes pilot inform the use of medical scribes in the VA including considerations of budgeting, resource utilization, and services where medical scribes may be most beneficial.

Key Questions

KQ1: What is the effect of medical scribes in cardiology, orthopedic, or emergency department clinics?

KQ2: How do the effects of medical scribes vary based on differences in compensation structure (ie, contracted through vendor or employees of the institution), qualifications (ie, training, accreditation, experience), types of entries (ie, medical orders, medical history, coding [billing, diagnoses, complexity/comorbidities]), or setting (ie, rural, urban, access-challenged)?

PICOTS

Population(s): Adult patients and/or practitioners in cardiology, orthopedic, or emergency department clinics

Interventions: “Medical scribe” or document assistant program that involves navigation of electronic health record system (must provide some information about scribe responsibilities/duties)

Comparator: Any

Outcome(s): Clinic efficiency; patient and practitioner satisfaction; healthcare system outcomes (cost, time to train, turnover, errors, quality)

Setting: Effectiveness and characteristics of medical scribe interventions within cardiology, orthopedic, or emergency department settings.

General Search Strategy

MEDLINE, Embase, CINAHL

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Developing Culture of Innovation: A Systematic Review

Key Questions

KQ1: How is culture of innovation defined in the literature?

KQ2a: What are key characteristics of programs to improve or establish a culture of innovation?

KQ2b: In assessments of these programs, what metrics are used to capture culture of innovation?

KQ2c: In assessments of these programs, what other outcomes or impacts are described?

PICOTS

Interventions: Programs designed to improve or establish a culture of innovation

Outcome(s): Culture of innovation, organizational innovation, organizational or workforce outcomes

Setting: Large healthcare systems in high-income countries

General Search Strategy

We will procure literature from databases including Ovid Medline, Business Source Complete, and PsycInfo using terms related to culture of innovation (eg, culture, climate, innovation, creativity).

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