VA HEALTH SERVICES RESEARCH & DEVELOPMENT 

FORUM 

JUNE 1999 

A Publication of the VA Office of Research & Development, Health Services Research & Development Service,

Management Decision and Research Center, in conjunction with the Association for Health Services Research

IN THIS ISSUE 

Commentary . . . . . . . . . . . . . . . . . . . . . . . 1 

Response . . . . . . . . . . . . . . . . . . . . . . . . . . 2 

Research Highlights . . . . . . . . . . . . . . . . . 4 

Organization Profile . . . . . . . . . . . . . . . . .6 

QUERI Update. . . . . . . . . . . . . . . . . . . . . .8 

C OMMENTARY 

HSR&D in the 21st Century: 


Where We Are and Where We Need To Be


By John G. Demakis, M.D., Director, HSR&D 

Not too long ago, VA’s Health 

Services Research and Development 

Service (HSR&D) had a budget of 

$1 million and peer reviewed 13 

proposals. Today, we have a budget 

of $42 million and more than 200 

funded projects, centers, and career 

development/scientists awardees. 

We have some of the most skilled 

health services researchers in the 

nation, as evidenced by their roles 

as editors of a major HSR&D journal, immediate past president of the 

Society of General and Internal 

Medicine, and president of the 

Society for Medical Decision 

Making. We have built relationships with VA Headquarters and 

Networks to enhance the usefulness 

and timeliness of our research 

efforts to the system. So what 

should we be doing differently as we 

move into the next millennium? 

Plenty. 

One thing we know for certain 

about health care and health care 

delivery systems today and in the 

near future is that they are changing. For many years, even as 

health care delivery was changing 

in the private sector, VA remained 

a protected, insular system that 

provided tertiary care. However, 

when Dr. Kizer became Under 

Secretary for Health, he set the VA 

health care system on a long journey of change. This journey provides exciting opportunities for the 

HSR&D Service. Studying systems 

and the effects of change on systems, individuals, and policy is 

what HSR&D does well. The organization and delivery of health care 

will continue to change during the 

next five to 10 years – both in the 

VA and in the private sector. New 

research findings from HSR&D can 

and will make major contributions 

toward shaping and directing those 

changes. 

Preparing For Change 

Relationships with VISNs and 

HQ. We need to become more systematic in our approach to identifying and selecting questions to 

answer for the VA system. This 

will require a closer working relationship with policy makers and 

decision makers. As a result, use 

O ur findings should 

lead to changes in policies, 

practices, and patient 

outcomes. 

of our Service Directed Research 

Program may increase. We already 

work closely with Network Directors 

through our HSR&D/Network 

Liaison Committee to identify 

important areas of study, but we 

will need to expand upon these 

efforts and create new opportunities for dialogue so that together 

we can identify and prioritize 

research questions. Then HSR&D 

will issue new solicitations that 

will help us get answers to those 

questions — and get them in a 

timely manner. 

We have recently funded several 

new efforts with Networks through 

our VISN Collaborative Research 

(VCR) solicitation. Through VCR, 

HSR&D works with the Networks 

to enhance VA health services 

research capacity and expertise to 

address important health services 

research issues of interest to 

Networks and the broader VA. 

Studies recently funded under this 

solicitation address mission-critical 

questions and focus on issues such 

as enhancing patient access to primary, emergency room, or specialty 

care; determining the optimal 

staffing level, panel size, or geographic location of specific treatment programs; and evaluating 

innovative care delivery systems. 

These studies will add generalizable knowledge to the health services literature and also inform key 

policy and programmatic decisions. 

We will evaluate VCR studies as 

they move forward to see if we 

should expand this type of work. 

So far, we have focused VCR efforts 

in Networks that don’t currently 

have an HSR&D Center of 

Excellence. Perhaps we should 

open these up to all Networks. 

continued on page 2 
2 

C OMMENTARY 

Commentary 

continued from page 1 

Building and Maintaining 

Capacity 

Research Centers: We currently 

have 11 Centers of Excellence and 

the Management Decision and 

Research Center, which have 

proven to be invaluable resources. 

Additional needs resulted in the 

funding of our newest centers, the 

VA Information Resource Center 

and the Cost Economics Center. 

We are still determining whether 

these very successful centers possess enough field capacity. During 

the next few years, we will be taking a closer look at our capacity 

and considering new and creative 

ways to enhance it. 

Career Development/Scientist 

Program: I would like to see 

expansion in our Career 

Development Program during the 

next five years. We currently fund 

46 clinicians and eight doctoratelevel scientists through our Career 

Development/Scientist awards, 

which provide protected time for 

W e need to strive for a 

healthy balance of longterm research and rapid 

response research. 

these talented investigators to 

advance their research careers and 

increase the health services 

research knowledge of other VA 

clinicians and non-clinicians. In 

addition, we may need to seek different skill sets in our Career 

Development awardees of the 

future. For example, we need more 

non-physician clinicians (nurses, 

clinical psychologists, social workers, etc.) that bring new and different perspectives to our research 

portfolio. We need career scientists 

continued on next page 

Response 

VHA Needs Health Services Research To 

Continue the Journey for Change 

By Robert H. Roswell, M.D., Veterans Integrated Services Network Director 

In the current austere budget climate, many of us may be tempted to ask 

whether the Veterans Health Administration (VHA) can continue to support health services research. My answer is a resounding “Yes!” I would 

like to share my thoughts on why. 

About four years ago, VHA began a remarkable transformation under the 

visionary leadership of Dr. Kenneth Kizer. The cornerstone for this transformation was the creation of 22 Veterans Integrated Service Networks 

(VISNs), and the decentralization of substantial authority to the leadership 

within each VISN. While the delegation of authority on this level was somewhat unprecedented for a large federally funded agency, what took place 

next was even more extraordinary. Stimulated by a new emphasis on performance measurement and accountability, the VISNs began making meaningful changes in the delivery of health care services to veterans. More 

importantly, significant operational efficiencies were put in place that 

allowed us to reach hundreds of thousands of new veteran service users, 

despite a relatively fixed operating budget. Hundreds of new access points 

opened, and patient-focused, primary care became the new service standard. 

To a casual observer, the community-based, outpatient delivery of highquality, well-managed health care services that characterizes VHA in 1999 

bears little resemblance to the staid bureaucracy of a national hospital system for veterans that was VHA just a few short years ago. Yet, an increasing number of pundits in Washington have charged that VA no longer 

provides uniform care and services across the country, and that new users 

and limited dollars have become the enemy of quality health care, particularly in specialized treatment areas. These critics often suggest that we 

need to re-centralize authority and reign in the innovative approaches 

that have enhanced care across the 22 VISNs. 

Our real needs, of course, are much different. We need a mechanism to 

assess the effectiveness of disparate approaches to common challenges. 

We need a way to evaluate the actual savings associated with innovative 

health care delivery processes. We need a means to measure quality, 

access, patient satisfaction, and functional outcomes against these costsavings. And, even more importantly, we need to share those strategies 

that have proved successful across the 22 networks. Without these things, 

we may be forced to abandon the very process that has brought us so 

much innovation and improvement. 

The answer to this dilemma does not lie in Washington but in VHA’s 

own tremendous health services research capability. Our challenge now is 

to utilize this expertise to measure variations in practice, validate health 

care outcomes, and assess the operational efficiency of the many innovations in care in place all across our system. We have neither the time nor 

the resources to seek answers from outside. We must draw upon the 

excellence in health services research within VHA to meet this pressing 

need. And, just as importantly, we must pursue strategies that will develop and inculcate all 22 VISNs with the expertise in investigative and statistical techniques that will allow us to continue our dramatic success in 

reshaping veterans’ health care delivery for the coming millenium. 

Can we continue to afford health services research in VHA? We can’t 

afford not to! 
3 

C OMMENTARY 

Commentary 

continued from page 2 

with expertise in organizational 

behavior, change management, 

health economics, and database 

management. 

Developmental Projects 

Program: Another way to build 

and maintain our capacity is 

through our Developmental 

Projects Program. During the next 

few years, I hope to focus more 

attention on this program, which 

provides seed money for investigators to apply innovative health services research methods to problems 

that have direct relevance to VA’s 

clinical mission. This program will 

need to be expanded and refocused 

to meet our evolving needs. 

Data Needs 

Increasingly, our ability to carry 

out research projects is dependent 

on the availability of reliable data. 

Fortunately, the VA has a series of 

national databases that cover inpatient, outpatient, and long-term 

care. Unfortunately, these databases are not linked and some are 

more reliable than others. In addition, since so many of our patients 

are also eligible for Medicare, many 

of our projects require Medicare 

data to get a true picture of veterans’ health care utilization. We 

need to be able to link the various 

VA databases and link our databases with Medicare databases in a 

systematic, prospective fashion. We

have recently initiated projects that

will address these issues. 

Making A Difference 

In HSR&D, we must be able to 

show that what we do makes a difference. Our findings should lead 

to changes in policies, practices, 

and patient outcomes. We especially need to document improvements 

in patient outcomes. This is what 

our Quality Enhancement Research

Initiative (QUERI) is all about. I 

expect to devote more time and term research and rapid response 

resources to QUERI in the next five research. Keeping pace with 

years. However, in this rapidly changes in health care delivery will 

changing health care environment, surely be an important challenge 

we need to accept the fact that we for us in the new millennium. 

can’t always take several years to In summary, I believe HSR&D is 

answer a question. We simply well positioned within VA to make 

don’t have the luxury if our work is major contributions to VA’s efforts 

to be relevant, so we must speed up to improve quality, patient outour response time. We need to comes, and cost. Our challenge is 

strive for a healthy balance of long- to do just that. 

Response 

Collaboration Between HSR&D Researchers 

and Managers Will Move VHA System 

Toward Evidence-Based Medicine 

By Robert A. Petzel, M.D., Veterans Integrated Services Network Director 

The keys to the future success of the Veterans Health Administration 

(VHA) in maintaining and improving the health of America’s veterans 

are clear. First, VHA’s delivery system must be solidly grounded in evidence-based medicine. Second, we must find the most cost-effective 

ways to deliver the most efficacious health care services. This involves 

expanding the evidence base for our practice and finding methods to 

translate this knowledge into actual clinical practice. 

VHA is in an excellent position to do just that. For one thing, VHA is 

an integrated national health care system. In addition, as Dr. Demakis 

has outlined, we have an outstanding Health Services Research and 

Development (HSR&D) organization, which includes 11 Centers of 

Excellence, a $42 million budget, hundreds of funded investigators, and 

a robust career development program. Finally, we have an opportunity 

to integrate the activities of the HSR&D program with the management 

of our national system of VHA networks and medical centers. 

During the past few years, VHA’s managers and HSR&D researchers 

have engaged in a much closer collaborative relationship. HSR&D has 

invited managers to identify specific areas – such as access to care, 

women’s health, and nursing – where further research could be of assistance to them. Efforts are underway to stimulate HSR&D programs in 

all VISNs. The Quality Enhancement Research Initiative (QUERI) has 

been launched with the goal of improving the evidence base for those 

clinical conditions most commonly seen in our patient population. 

Finally, the HSR&D Liaison Committee, which is composed of HSR&D 

researchers, network directors, clinical managers, and quality managers, 

has been effective in increasing the relevance of the HSR&D program. 

Investigator-initiated research is still the best research, but HSR&D’s 

efforts have helped stimulate that research and improve its relevance to 

managing VHA. 

VHA has the opportunity to demonstrate to the rest of the country 

that evidence-based health care is the most effective, lowest-cost, and 

highest-quality health care. To do this, we must continue to expand 

and improve productive collaborations among our health services 

researchers and managers. 
4 

R ESEARCH HIGHLIGHTS 

HSR&D’s Investigator-Initiated Research Targets
 

Diverse Areas of Interest to VA
 

By Claire Maklan, M.P.H., Ph.D., and Mary Jones, M.B.A. 

VA’s Health Services Research and Access – Published October 1996 with differences in patients’ ethnic 

Development Service (HSR&D) is and June 1997 and cultural identity. 

committed to a program of research Studies focused on the outcomes of 

that provides timely and useful infor­ actions planned or taken by VA Patient-Centered Care – 

mation for improving the effective­ managers or policy makers with the Published September 1997 and 

ness, cost effectiveness, and quality intent of improving access, either by October 1998 

of VA health care. To accomplish increasing it, restricting it (to Studies of processes and outcomes 

this objective, HSR&D’s reduce unnecessary or ineffective of care that are sensitive to 

Investigator-Initiated Research (IIR) services), or redistributing it across patients’ individual values and prefprogram supports two types of pro­ populations or places. erences, with emphasis on qualitajects: (1) unsolicited studies in all tive methods. 

VA-relevant areas of health services VA Managed Care – Published 

research; and (2) studies that November 1996 and June 1997 Rehabilitation Outcomes – 

address particular research themes Research that addresses timely Published April 1997 and April 

or questions articulated in requests questions about how VHA’s move­ 1998 

for proposals. ment toward managed care and Collaborative initiative between 

The overall steady growth in the adoption of specific managed care HSR&D and VA’s Rehabilitation 

IIR program during the last several principles or practices affect impor­ Research and Development Service 

years has been accompanied by a tant patient and system outcomes. to encourage studies of the outmarked increase in the proportion of Of particular interest are studies comes of rehabilitation services, 

projects focused on questions and focused on the effectiveness and with the aim of improving patient 

topics identified by HSR&D as high efficiency of primary care in the physical functioning, independence, 

priority to VA managers, policy new, increasingly “managed” con­ and quality of life. 

makers, and clinicians. text. 

In approximately 30 months, we Patient Safety – Published May 

have published solicitations for IIR Implementation of Clinical 1998 and February 1999 

proposals in 14 distinct areas of Practice Guidelines – Published Studies to identify high-risk 

research. While these do not all rep­ November 1996, June 1997, and patients, providers, processes, and 

resent new areas of research for Fall 1998 situations; as well as to identify 

HSR&D, this programmatic direction Studies to identify effective methods strategies for reducing and elimihas resulted in a respectable start in or strategies for implementing clini­ nating adverse events, thereby 

several new areas as well as increased cal practice guidelines in VA health improving patient outcomes and the 

investment in some traditional areas care, especially strategies that may overall quality of care. 

of health services research. In addi­ be replicated systemwide and studtion, this more directed approach has ies that address generic issues in Cross-Cutting Issues in 

brought some new investigators to guideline implementation. Telemedicine – Published 

HSR&D and has channeled the ener­ September 1998 

gy of some established HSR&D inves­ Women’s Health / Gender Research and systematic evaluatigators in new areas. Variations – Published November tions on the effectiveness or cost 

In the following section, we identi­ 1996 and June 1997 effectiveness of telemedicine applify and briefly describe each of Research on the special health care cations in VHA, with attention to 

HSR&D’s solicitations for IIR stud­ needs of women veterans and stud­ generalizable concepts. 

ies, in order of publication date. ies to explain variations in practice 

Currently, these solicitations are and outcomes associated with gen­ QUERI – Published October 1998 

still open. For the most up-to-date der differences. Under the Quality Enhancement 

information, visit our web site at Research Initiative (QUERI), HSR&D 

www.va.gov/resdev/fr/frrfp. Ethnic and Cultural Variations requested proposals for studies of 

Projects funded to date or pending – Published November 1996 and health care quality related to five of 

award in each area are listed in the June 1997. the QUERI clinical foci: chronic 

accompanying table. Studies to explain variations in heart failure, HIV/AIDS, substance 

practice and outcomes associated abuse, diabetes, and stroke. 
Funded Projects Responsive to Targeted IIR Solicitations 

TITLE Project Number Location Start End 

Access 

Impact of Outsourcing VA Cardiac Surgery on the Cost and Quality of Care ACC 97.004 Cleveland Oct-97 Sep-00 

Enhancing Access to Primary Care for Veterans with Psychiatric Illness ACC 97.021 San Diego Oct-97 Sep-98 

Efficacy of Telepsychiatry in the Treatment of Depression ACC 97.034 Baltimore Oct-97 Sep-00 

Processes, Structure, and Outcomes of Post-Stroke Rehabilitation Care ACC 97.114 Kansas City Oct-97 Mar-00 

Pressure Ulcer Assessment via Telemedicine ACC 97.013 Ann Arbor Oct-98 Mar-00 

An Evaluation of the Organization of Subspecialty Cardiac Care within VA ACC 97.079 Seattle Jan-98 Jun-00 

Improving Service Delivery through Access Points ACC 97.068 Little Rock Jan-99 Dec-01 

Managed/Primary Care 

An Integrated Model of Primary Care in Mental Health MPC 97.010 Indianapolis Aug-97 Jul-00 

Negotiating Patient Expectations and Requests in a Managed Care Environment MPC 97.011 Durham Sep-97 Aug-99 

Evaluating HEDIS 3.0 for VHA MPC 97.002 Bedford Oct-97 Sep-99 

Ambulatory Case Mix Measures: Implications for VA Managed Care MPC 97.009 Bedford Oct-97 Sep-00 

The Effect of Managed Care on VA Hospital Costs MPC 97.008 Bedford Oct-97 Sep-01 

Managed Care Performance of VHA Primary Care Delivery Systems MPC 97.012 Sepulveda Oct-97 Sep-99 

Clinical Practice Guidelines 

Guidelines for Drug Therapy of Hypertension: Closing the Loop CPG 97.006 Palo Alto Jan-98 Jun-00 

A Randomized Trial to Implement the AHCPR Smoking Cessation Guideline CPG 97.039 Minneapolis Jul-98 Jun-01 

Implementing Smoking Cessation Guidelines: ... Evidence-Based Quality Improvement CPG 97.002 Sepulveda Jul-98 Jun-02 

Impact of Provider Substance Abuse Education on Guideline Implementation CPG 97.011 Cleveland Oct-97 Sep-00 

Pressure Ulcer Care in Nursing Homes: Effect of Clinical Guidelines CPG 97.012 Bedford Oct-97 Sep-00 

Computerized Guidelines Enhanced by Symptoms & History: Clinical Effects CPG 97.001 Indianapolis Aug-97 Feb-01 

A Multi-site Study of Strategies for Implementing Schizophrenia Guidelines CPG 97.027 Little Rock Aug-97 Jul-00 

Three projects pending final decision. 

Women’s Health/Gender Variations 

Gender Differences in Compensation and Pension Claims Approval for PTSD GEN 97.002 Minneapolis Oct-97 Sep-00 

Toward Gender-Aware VA Health Care: Staff Ideology, Sensitivity, & Knowledge GEN 97.014 Boston Oct-97 Sep-00 

Veteran Women’s Alcohol Problems: Prevalence, Screening and Self Help GEN 97.022 Seattle Oct-97 Sep-01 

Surgical Risks and Outcomes of Women Treated in VA Hospitals GEN 97.016 Hines Oct-97 Sep-99 

Decision Making for Depression in Women Veterans: Patient & Physician Factors GEN 97.023 Bedford Jul-98 Jun-01 

Ethnic and Cultural Variations 

Cultural Factors in Adaptation to Chronic Illness ECV 97.009 Tucson Apr-97 Sep-98 

Race, Patient Preference, and Stroke Risk Reduction ECV 97.020 Durham Jul-97 Jun-00 

Educat’l Efforts to Reduce Cultural & Ethnic Variation in Cardiac Procedure Use ECV 97.026 Pittsburgh Jul-97 Jun-99 

Ethnicity & Veteran Identity as Determinants of VA Ambulatory Care Use ECV 97.028 West LA Jul-97 Jun-01 

Ethnic/Cultural Variations in the Care of Veterans with Osteoarthritis ECV 97.014 Cleveland Oct-97 Sep-00 

Delivery of MH Services to American Indians & Hispanic Americans in NM & MN ECV 97.005 Minneapolis Oct-97 Sep-99 

Prostate Cancer Outcome Measures: Age and Race Effects ECV 97.081 Bedford Apr-98 Mar-00 

Racial Variations in Cardiac Procedures: Do Health Beliefs Matter? ECV 97.022 Bedford Oct-98 Sep-00 

Ethnic Differences - Management of Patients with Ischemic Heart Disease ECV 97.082 Cleveland Jul-99 Jun-03 

Health Seeking Behavior and Treatment Selection in Patients with Coronary Disease ECV 98.100 Houston Jul-99 Aug-02 

Patient-Centered Care 

Complementary Medical Treatment among Veterans Accessing VA Primary Care PCC 98.033 Tucson Oct-98 Sep-00 

Communication, Alternatives, and Preferences in End-of-Life Care PCC 98.070 West Haven Jan-99 Dec-01 

An Illustrated Patient Satisfaction Evaluation Tool for Ambulatory Populations PCC 98.071 Philadelphia Jan-99 Mar-02 

Documenting Barriers to Patient-Centered Care in an Academic Clinic PCC 98.010 Boise Apr-99 Mar-02 

Developing a Cancer Pain Prognostic Scale PCC 98.068 E. Orange Jul-99 Jun-02 

Patient-Centered Alternatives to Psychiatric Hospitalization for Veterans PCC 98.051 San Diego Jul-99 Jun-02 

Development and Evaluation of a Hormone Replacement Therapy Decision Aid PCC 98.039 Milwaukee Jul-99 Jun-03 

Assessing the Needs of VA Patients with Advanced Cancer PCI 99.176 Madison Jul-99 Jun-01 

Treatment Decision Intervention for Veterans with Prostate Cancer PCI 99.159 Lakeside Jul-99 Jun-01 

Rehabilitation Outcomes 

Outcome of Lower Extremity Constraint-Induced Therapy after Stroke O2356 RA Birmingham Oct-98 Sep-02 

Validation and Field Testing of a National Pain Treatment Outcome System O2357 RA Tampa Jul-98 Jun-02 

Impact of Occupational Therapy on the Health Status of Elderly Veterans O2364 RA Lexington Oct-98 Sep-01 

Patient Safety 

One project pending final decision. 

Quality Enhancement Research Initiative 

Diabetes 

Improving Diabetes Care via Automated Telephone Assessment and Patient Education DII 99.187 Menlo Park Jul-99 Jun-03 

Developing and Implementing a Quality Measure for Glycemic Control DII 99.205 Bedford Jul-99 Jan-03 

Chronic Heart Failure 

One project pending final decision. 

HIV/AIDS 

One project pending final decision. 

5 
6 

O RGANIZATION PROFILE 

HSR&D’s MDRC Connects Research with VA 


Policy and Management
 

By Martin Charns, D.B.A., Director, MDRC 

Within VA’s Health Services 

Research and Development Service 

(HSR&D), the Management 

Decision and Research Center 

(MDRC) serves as a bridge 

between research expertise and 

management and policy making at 

VA. Launched in 1992, the MDRC 

provides VA senior staff with consultation, technical assistance, 

management information, and 

research findings. 

Often, complex organizations 

need to have individuals or entities 

that serve as integrators, or bridging mechanisms. The literature 

has shown that most effective integrators are those who are able to 

work effectively in both areas that 

they are attempting to integrate. 

MDRC staff understand and have 

expertise in both research and management. Its programs help translate information from one side to 

the other, so that it can be used 

effectively for the VA system. This 

integrating function, which bridges 

the world of research with the 

world of practice, is the added value 

that the MDRC brings to VA. 

The MDRC’s four strongly interdependent programs provide VA 

researchers and managers with a 

range of services designed to help 

them find solutions to myriad problems in health care delivery. 

Management Consultation. The 

MDRC’s Management Consultation 

Program responds to requests from 

VA senior managers and policy 

makers, using resources and expertise within HSR&D. Traditionally, 

MDRC staff have worked with the 

Centers of Excellence, occasionally 

with other health services 

researchers within VA, and less 

often with health services 

researchers at universities who are 

not VA staff. As VA’s needs have 

evolved under the ongoing transformation, the MDRC staff is execut­ health services research within VA 

ing more work, using its own man­ and communicates research findagement and research expertise. ings to audiences in and outside 

The range of responses is great, VA. The program uses a variety of 

from very quick responses on policy media, including conferences and 

issues and organizational consulta­ various publications, electronic distions to three- or even four-year semination, management lectures, 

studies, like the Service Line Study and satellite broadcasts. Although 

and the Integration Study, which the dissemination vehicles vary 

reflect major organizational considerably, the overall purpose is 

changes that take some time for the same: to take information from 

their effects to be measured. The the research community, put it in 

MDRC has done more than 70 con­ an understandable form and lansultation projects, including some guage, and disseminate it via the 

that have helped shape the organi­ most effective vehicle possible to 

zation and management of VA. targeted audiences that may 

The MDRC hopes to continue in include policy makers, managers, 

that role. clinicians, researchers, and others. 

Highlights include the primer 

Information Dissemination. series, the satellite broadcast on 

The Information Dissemination guideline implementation, and the 

Program fosters dialogue about VA Research and Development web 

G. Richard Smith Leaves Directorship of 

HSR&D Arkansas Center 

After eight years as the Director of the VA Health 

Services Research and Development (HSR&D) Center 

for Mental Healthcare and Outcomes Research 

(CeMHOR) in Little Rock, G. Richard Smith, Jr., 

M.D., has stepped down to move on to other challenges. Now, he says, he will pursue his interest in 

improving health care in Arkansas, working with the 

Arkansas Center for Health Improvement (ACHI), 

which he established in collaboration with the 

Arkansas Department of Health. G. Richard Smith 

Dr. Smith developed CeMHOR, serving as its director from its inception in 1990 through 1998. He was responsible for 

transforming CeMHOR from a six-person research unit with support staff 

to a full-fledged research program with 18 doctoral level investigators. 

Dr. Smith has been instrumental in developing processes and technology for mental health care quality improvement, including disorderspecific outcomes modules. He also served on depression guidelines 

development committees for VA and the American Psychiatric 

Association. 

ACHI, where Dr. Smith will be devoting a substantial amount of his 

time, is an independent, nonpartisan organization. 
7 

O RGANIZATION PROFILE 

page. All of the Information 

Dissemination Program’s efforts 

utilize a variety of media that best 

meets the needs of VA and non-VA 

targeted audiences. 

Technology Assessment. The 

Technology Assessment Program 

(TAP) came about at the request of 

then-Acting Under Secretary 

Farrar, who wanted a scientific 

basis for VA’s technology decisions. 

TAP’s mission is to enhance the 

quality of care and efficiency of 

resource use by promoting evidence-based clinical practice. It 

serves as a scientific and education 

resource for other VA technology 

assessment activities, particularly 

the Technology Recommendations 

Panel. 

TAP also works directly with 

the networks. Sometimes, a network director or clinical manager 

has a question about whether a 

particular procedure is supported 

by scientific evidence or whether 

there is any evidence available on 

it. TAP conducts a systematic 

review of the literature, usually in 

concert with other experts within 

HSR&D, to make those determinations. These reviews are then sent

out to other experts for a critique 

before they are released. In this 

way, program staff try very hard to

balance timeliness with quality. 

Clearly, it is important to get 

information to the field as quickly 

as possible, but it is equally important for the program to maintain 

the quality of its work. Otherwise,

its usefulness and credibility are 

diminished. 

Management and Organization 

Research. The Management and 

Organization Research Program 

conducts competitively funded 

research on organizational and 

managerial factors affecting the 

access, cost, and quality of patient 

care; quality of work life for health 

care staff; and workplace dynamics 

and the implementation of change. 

Highlights include the National VA 

Quality Improvement Study and 

the study of staff coordination and 

surgical outcomes conducted in col­ pating many of these changes; it 

laboration with the National VA even helped move some of them 

Surgical Risk Study. These studies along. For example, the MDRC 

are very much in sync with the came out in 1994 with a report 

changes that are going on in VA. that was a blueprint for creating 

networks, and now VA has The MDRC has accomplished a Veterans Integrated Service great deal since its inception, and Networks (VISNs). What will hap­ many of its products have had a sig­ pen next? Can the MDRC be part nificant impact on VA management of the next wave and anticipate and policy. A few examples include how research can contribute to the primary care primer, which changes that are occurring in oper­ came out just as VA made its push ations? into primary care, the conference HSR&D is busier than it’s on organizational transformation, ever been, and the MDRC is busier and the technology assessment of than it’s ever been. The MDRC positron emission tomography must be aware of capacity issues (PET). That assessment is the for meeting requests for services world’s most comprehensive report and managing the work in a way on PET. Based on that report, that maintains quality and timeli­ which found little evidence to sup­ ness. port the use of PET as a diagnostic Prospects are great. The tool for specific clinical conditions, MDRC’s research interests revolve VA decided not to invest in addi­ around organization design and tional PET centers. change. There is no better opportunity right now to study that Challenges and than within VA. As VA moves for­ Opportunities ward with creating a model for 

The MDRC faces several chal­ health care delivery, the MDRC is 

lenges. The world is changing, and pursuing the opportunity to study 

VA is changing with it. Can the how that goal is achieved. For the 

MDRC keep ahead of that curve? MDRC, that is indeed a very excitSo far it’s done a good job of antici­ ing opportunity. 

Nelda Wray Leaves Helm of Houston Field 

Program for New Baylor Position 

Nelda P. Wray, M.D., M.P.H., who was instrumental in launching the Health Services Research and 

Development (HSR&D) Center of Excellence in 

Houston and has served as its director for eight 

years, has left that position to head up a new 

health services research section at Baylor College 

of Medicine. 

Among her many accomplishments, Dr. Wray 

helped develop and staff the Houston Center of 

Excellence, which was approved in 1988 and now Nelda Wray has a staff of nearly 50. 

Under Dr. Wray’s leadership, the Houston field program has 

made outstanding contributions to VA research, including its ongoing work with large database analysis, both within and outside VA. 

Dr. Wray will remain at the Houston Center for Excellence as a lead 

researcher and mentor. 
8 

QUERI Update: VA Demonstrates Good Outcomes 

for Heart Attack Treatment 

The Quality Enhancement Research Initiative ■ Key validated quality measures for veterans with

(QUERI) is a major effort by HSR&D to translate acute myocardial infarction (AMI) exceed those in the

research discoveries and innovations into patient care private sector in the use of aspirin, beta blockers, ACE

and systems improvements. QUERI focuses on eight inhibitors, and in the avoidance of calcium channel blockers.

conditions: ischemic heart disease, chronic heart fail­ ■ Because some patients cannot be treated with all ure, diabetes, stroke, mental health, substance abuse, recommended therapies due to absolute or relative spinal cord injury, and HIV/AIDS. As findings from contraindications, guideline compliance for treatment of QUERI emerge, they will be reported in FORUM. AMI within VHA may be approaching optimal levels. 

■ Cardiac procedure use was comparable or greater Treatment for heart attack patients provided at VA than in the private sector. primary and tertiary facilities is comparable or superior in quality to treatment provided in the private VA performance data for the QUERI IHD study were 

sector, according to early findings from the QUERI obtained from multiple sources, including chart reviews 

Ischemic heart Disease (IHD) study. Among the and clinical trials. Benchmark data were obtained from 

findings: the National Registry of Myocardial Infarction. 

Rudolf Moos Receives Under Secretary’s 

Award for Health Services Research 

Rudolf H. Moos, Ph.D., of the Health Services 

Research and Development Service (HSR&D) Center
 

of Excellence in Palo Alto, is the first recipient of the
 

Under Secretary’s Award for Outstanding 

Achievement in Health Services Research. Deputy 

Under Secretary for Health Thomas Garthwaite, 

M.D., presented the award to Dr. Moos on Feb. 25th 

at a ceremony held during the HSR&D Annual 

Meeting in Washington, DC. 

The Award was established in 1998 to honor the Rudolf Moos highest level of achievement in health services
 

research and to recognize its importance to the health care of veterans 

and non-veterans alike. 

In a career spanning more than 35 years, Dr. Moos has worked to 

improve the lives of veterans affected by substance abuse and/or psychiatric disorders. He currently serves as director of HSR&D’s Center for	 

Health Care Evaluation and the Program Evaluation and Resource 

Center. 

F O R U M 

Martin P. Charns, D.B.A., Editor-in-Chief 

Mary Darby, Editor

Geraldine McGlynn, M.Ed., Co-editor

ADVISORY COMMITTEE 

Carol M. Ashton, M.D., M.P.H., VA HSR&D 

Center of Excellence, Houston

John G. Demakis, M.D., Director, VA HSR&D 

Rodney A. Hayward, M.D., VA HSR&D 

Center of Excellence, Ann Arbor 

David H. Law, M.D., VA Medical Center, 


Bay Pines, FL
 

Shirley Meehan, M.B.A., Ph.D., VA HSR&D 

Alan S. Perry, VA Medical Center, Roseburg

Robert M. Roswell, M.D., VA Network #8,

Birmingham

Forum is a Publication of the VA Office of Research &

Developemnt, Health Services Research & Development 

Service, Management Decision and Research Center, in

conjunction with the Association for Health Services


Research.