V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K
VA Research
PUTTING THE “D” IN R&D
Increasing the real-world impact of VA research By Craig Collins
n AMONG THE THOUSANDS OF STUDIES conducted at Department of Veterans Affairs (VA) medical centers, outpatient clinics, and nursing homes every year, innovations abound. In 2006, for example, when a high percentage of military service members returning from Iraq and Afghanistan suffered from post-traumatic stress disorder (PTSD), VA mental health researchers and clinicians attacked the problem with an evidence-based intervention, cognitive-processing therapy (CPT), that VA clinical psychologist Patricia Resick, PhD, had been researching since 1988. The initiative to disseminate CPT throughout the VA brought relief not only to veterans, but to other Americans suffering from PTSD. Today, CPT is considered a leading cognitive-behavioral treatment, a frontline intervention for PTSD. The expansive, integrated structure of the Veterans Health Administration (VHA), with more than 9 million patients treated at about 1,240 facilities, presents a unique opportunity for its more than 20,000 mental health professionals to move the work of investigators such as Resick into clinical practice. But the size and scope of the VHA can also present some challenges. Amy Kilbourne, PhD, MPH, director of the VHA’s Quality Enhancement Research Initiative (QUERI), is a national expert in implementation science: the study of methods and strategies to promote the uptake of proven interventions into routine practice. Following on the success of the CPT initiative, she said, VA’s Health Services Research and Development Service (HSR&D) turned its focus to getting more veterans into treatment for depression – one of the most common mental health conditions facing veterans and a condition associated with greater suicide risk. In 2008, the VA estimated that about 1 in 3 veterans who visited primary care clinics had some symptoms of depression; 1 in 5 had serious symptoms that required further evaluation; and 1 in 8 had major depression requiring treatment with psychotherapy or antidepressants. The challenge for VA clinicians wasn’t that they didn’t know how to treat these veterans, Kilbourne said – it was that its mental health experts often weren’t interacting with the veterans who needed help. “We had great programs,” she said, “but they were all in psychiatry.” In most VA facilities, mental health clinicians were “embedded” in departments distinct from the primary care settings that accounted for the majority of patient interactions. “VA saw right away that essentially confining depression treatment into a mental health specialty was not going to make a realworld impact,” said Kilbourne, “because most veterans were not going to a mental health specialist first to get depression care. They were going to their primary care doctor.”
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In response, the VA launched an effort similar to the one that made CPT more widely available to veterans. Investigators and practitioners created and tested, through a series of rigorous studies, a model to link veterans in primary care to mental health services: The collaborative care model, in which a team of professionals – including a primary care physician, a mental health clinician, a nurse, a social worker, and other team members – helps patients deal with depression symptoms. “Then they tested techniques to improve the process by which depression treatment was occurring,” Kilbourne said, “and finally, they actually looked at the costeffectiveness of it and then tested different strategies to maintain the depression treatment in primary care programs in the VA. And then it became a nationalized program.” The wide-scale implementation and adoption of CPT for treating PTSD, and of the collaborative care model for relieving depression symptoms, are clear victories for VA research – the aim of which, after all, is to improve the health and lives of veterans. Many VA innovations are likewise validated by research, but there’s often a lag between proving their value and actually making them valuable. An often-cited study by health informatics experts at the University of Missouri suggested that despite the growth in medical research, it takes an average of 17 years for evidence-based findings to reach clinical practice – and only about 1 in 5 proven practices ends up being used regularly in the real world. “We’re wasting a lot of research dollars,” Kilbourne said, “when we’re not able to provide to our patients all the innovations that research has found to be effective in regular routine care.” Why does it take so long for evidence to make its way into practice? There are multiple reasons: Many investigators publish in peer-reviewed journals and get back to work, and it can take a long time for an idea to make it from the pages of a journal out into the real world, if it makes it at all. If it does, it will probably need to be adapted across different
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