The passage of the Evidence-Based Policy Commission Act of 2016 underscored the desire of Congress and the president to promote evidence-based policymaking through randomized program evaluations supported by enhanced data and methodological infrastructure. PEPReC evaluates, refines, and supports rigorous randomized designs that are targeted for maximum impact on access to care, quality, and value within the VHA. PEPReC currently supports three randomized program evaluations:
Veteran-Directed Home and Community-Based Services Program (VD-HCBS): VD-HCBS is a program in the Office of Geriatrics & Extended Care providing participant-directed home- and community-based services to Veterans at risk for nursing-home placement. It presents an opportunity to bring the VHA's spending closer to that of other payers and, in doing so, aligns VHA's budgetary needs with patient preferences. The evaluation is a large-scale, stepped-wedge, cluster-randomized trial of up to 77 VAMCs who do not currently have the VD-HCBS program. Over a period of 34 months, these VAMCs are being randomized to times to begin offering VD-HCBS. The evaluation aims to understand whether VD-HCBS reduces hospital admissions, emergency department admissions, nursing home admissions, and health care costs relative to usual care among veterans at risk for nursing home placement.
Risk Stratified Enhancements to Clinical Care: Targeting Care for Patients Identified through Predictive Modeling as being at High Risk for Suicide (REACH-VET): Reach-Vet, in collaboration with Office of Mental Health and Suicide Prevention (OMHSP), is closely linked with Secretary Shulkin's priority of reducing the level of suicides among Veterans. The intervention includes a dashboard (REACH-VET) that ranks the risk for suicide for each VHA patient. The underlying model predicts increases in suicide rates of up to 30-40 fold for the first three months after cases are identified and 16 fold over one year for the 0.1% of patients at the highest predicted risk. Among the patients in the top 0.1% of risk at each site, roll-out of the dashboard has been mandated. On-site coordinators assist providers with dashboard use, patient identification, and re-evaluation of treatment plans. Sites are evaluated on the percentage of patients for whom coordinators ask providers to re-evaluate care within 2 weeks of REACH-VET identification and on the percentage of patients for whom providers attempt outreach within 2 weeks of REACH-VET identification. At this time, PEPReC and partners are applying to NIMH for funding to implement a randomized evaluation of centralized caring letters, to be sent over a one year period, that include decision support, help with coping skills, and assistance navigating the healthcare system.
Predictive Model-Based Targeted Risk Mitigation for Patients Receiving VA Opioid Prescriptions Who Are at High Risk of Adverse Events (STORM): As of 2013, almost one in four VHA patients with prescriptions received an opioid medication. As is evident from national trends, patients receiving them are at higher risk of overdose, death, and other adverse outcomes. The STORM tool is a predictive model to estimate the risk of opioid-related outcomes for Veterans with prescriptions for opioid medication. STORM also displays and tracks use of recommended risk mitigation strategies. Over the past year, PEPReC has worked with OMHSP, the New England Veterans Engineering Resource Center (VERC), and research partners at the VA Pittsburgh Healthcare System to develop the VHA policy that would lead to STORM's implementation. The policy would require facilities to review high-risk cases identified by STORM and some, randomly selected, would receive facilitation if they failed to reach case review targets. Furthermore, the threshold for "high-risk" will be adjusted in a cluster-randomized stepped wedge design.
Objective 1. Identify and select for evaluation high-priority policies or practices in collaboration with VA operational partners and VA Office of Research and Development (ORD).
Objective 2. Develop methodologies to conduct randomized program evaluations of selected policies of interest, using secondary data analyses that measure patient level outcomes.
PEPReC has three cores:
-The Quantitative Methods Core promotes and maintains publication-quality research design standards while conducting quantitative analysis of administrative data related to selected randomized program evaluations.
-The Partnership Core facilitates research-operations relationships through ongoing communication with potential project partners; review, refinement and selection of partnered evaluations; and collaboration coordination with operations and research.
-The Dissemination and Education Core promotes knowledge of and appreciation for evidence-based policy as an approach to effective management and accountability and trains the next generation of evidence-based policy researchers.
Specific methods vary by project with the common theme of leveraging administrative data to identify most effective policies and practices and equalize access to promising programs and policies. PEPReC performs randomized evaluations; randomization and implementation of programs evaluated will be conducted by operational partners.
Designing and initiating randomized initiatives in a large, integrated delivery system presents many challenges, including:
-Stability of intervention financing
-Means of controlling and commitment to adhering to randomized rollout
-Degree of buy-in from key implementation staff
-Feasibility of managing multiple veto points for interventions that span several programs.
PEPReC applies randomized program evaluation methods and innovative data resources to evaluate and refine quality improvement initiatives in essential areas of Veterans Health Administration (VHA) care. PEPReC's mission is to evaluate, refine, and support rigorous operations and policy evaluations featuring national databases and randomized designs that are targeted for maximum impact on access to care, quality, and value within the VHA.
- Yee CA, Pizer SD, Frakt A. Medicare's Bundled Payment Initiatives for Hospital-Initiated Episodes: Evidence and Evolution. The Milbank Quarterly. 2020 Sep 1; 98(3):908-974.
- Yuan Y, Thomas KS, Frakt AB, Pizer SD, Garrido MM. Users Of Veteran-Directed Care And Other Purchased Care Have Similar Hospital Use And Costs Over Time. Health affairs (Project Hope). 2019 Jun 1; 38(6):1037-1045.
- Garrido MM, Allman RM, Pizer SD, Rudolph JL, Thomas KS, Sperber NR, Van Houtven CH, Frakt AB. Innovation in a Learning Health Care System: Veteran-Directed Home- and Community-Based Services. Journal of the American Geriatrics Society. 2017 Nov 1; 65(11):2446-2451.
- Frakt AB, Trafton J, Pizer SD. The association of mental health program characteristics and patient satisfaction. The American journal of managed care. 2017 May 1; 23(5):e129-e137.
- Garrido MM, Minegishi T. Using VA Data to Inform the Design of Partnered Randomized Program Evaluations. HSR&D [Cyberseminar]. VA Information Resource Center (VIReC). 2017 Aug 29.
- Garrido MM. VD-HCBS evaluation plans: Briefing before the GEC-DAC (GEC'S data analysis center); 2017 May 23;
- Garrido MM. PEPReC's Planned Randomization and Evaluation Activities: Briefing before the Chief Consultant, Richard Allman and Chris Esmurdoc, National Program Manager of Purchased Care, Geriatrics and Extended Care; Kimberly Kelley, National Director, Home and Community Based Services; Kevin Foley, Program Specialist, Lori Gerhard, Director, Office of Consumer Access and Self Determination, Administration for Community Living; Margaret Kabat, National Director, VA Caregiver Support Programs; and Daniel Schoeps, Chief, Community Care Programs; 2016 Dec 16; Washington, DC.
- Prentice J, Pizer SD. PEPReC: Evolving the Learning Healthcare System: Briefing before the Chief Consultant, Care Management and Social Work Services, Mike Kilmer; 2016 Jul 12; Washington, DC.