Concern over accelerated health care costs

in the United States has increased sharply in

recent years. The per capita spending of

gross domestic product (GDP) in the

United States on health care is greater than

any other developed country. In 2006, the

United States spent $2.1 trillion, or 16 percent of GDP, on health care. This figure

translates to $7,026 per person annually, but

unlike other developed countries that provide near-universal coverage, 47 million

Americans (15.8 percent) lacked health

insurance in 2006.

One of the dominant drivers of rising

health care costs is technology related

changes in medical practice (38-62 percent).

Technology is pushed out into the field at

an alarming rate often before it is ready for

national deployment. Other factors that are

dramatically increasing health care costs include prices in the health care sector (11-22

percent), personal income growth (11-18

percent), changes in third party payments

(10 percent), administrative costs (3-10

percent), and aging of the population

(2 percent).

1

At its current rate of increase, the rising

cost of health care will be unsustainable in

the future. As a result of these driving

forces, researchers are examining a variety

of approaches to controlling or decreasing

health care costs.

One of the hot new areas in research that is

attempting to make an impact on improving

health care and controlling cost is comparative effectiveness. While there is no standard

definition of comparative effectiveness as

of yet, several definitions have been proposed by the Center for Medical Technology Policy, Congressional Budget Office,

and the Institute of Medicine. The VA

Office of Research and Development is

using the following working definition:

Comparative effectiveness studies are studies that

provide information on the comparative benefits

and/or harms of two or more alternative choices

for a given clinical condition, patient population,

or health care system. These choices can involve

medications, invasive therapies, non-pharmacologic

treatments, diagnostic tests and strategies, models

of care, or implementation strategies.

Given this working definition, the minimum

criteria for comparative effectiveness studies

include:

■ Comparison of two or more alternative

approaches;

■ Examination of patient outcomes (benefits and/or harms); and

■ Comparison between interventions,

modalities of care, or system attributes that

can affect care, but not among patient factors, or time periods.

F

Translatin

O

g research in

R

to quality

U

health care

M

for Veterans

Commentary

Comparative Effectiveness Research—

The New Imperative

Peter L. Almenoff, M.D., FCCP, Assistant Deputy Under Secretary for Health for

Quality and Safety, VA Central Office, Washington, D.C.

May 2009

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlights

• HIV Rapid Testing 4

• Future Prosthetic Costs 5

• Readmission for Heart

Failure 6

• HSR&D 2009 National

Meeting 7

A publication of the VA Office of Research & Development,

Health Services Research & Development Service, Center

for Information Dissemination and Education Resources, in

conjunction with AcademyHealth.
Comparative Effectiveness –

Research Methods

Different research methods are available for

the study of comparing effectiveness of

treatments. These methods include systematic reviews of existing research, analyses

of claims records, analysis of medical

registries, randomized controlled trials, and

computer modeling. Each of these methods

offers benefits and drawbacks.

Systematic reviews of research offer the

easiest method by utilizing existing studies

and synthesizing them to make additional

comparisons. Analyses of claims records

offer a more complex and time consuming

method by utilizing existing sources of raw

data. One advantage of this method is that

it provides new information to resolve

questions about treatments at a relatively

low cost. One of the main difficulties with

analyses of claims records, however, is that

such analyses do not account for patient

health status differences. Medical registries

are developed to track patients with a similar disease or similar specific treatment.

Randomized controlled trials are the

most definitive way to compare different

treatments but are generally very expensive

to perform and take a long time to complete. Computer models are programs that

simulate the effects of different treatments

on various populations. This method has

been suggested as an alternative or an addition to clinical trials. Each of these analytical methods offers advantages and

disadvantages in studying comparative

effectiveness; these techniques should be

customized depending on the research

question, or combined to answer specific

questions.

Clinical Effectiveness or Cost

Effectiveness?

There is current debate on whether federallyfunded comparative effectiveness research

should include consideration of cost effectiveness as well as clinical effectiveness.

Some of the main arguments against including

questions of cost effectiveness in comparative

effectiveness studies are that cost structures

vary across health care plans and, as a result,

findings might not be generalizable to

different plans or geographic areas. In addition, analysis of cost effectiveness might

have a negative bias on the analysis of

clinical effectiveness, leading to concerns

that such analysis may result in restricted

access to effective treatments. One advantage of considering cost effectiveness in

federally-funded comparative effectiveness

research is that it would encourage greater

transparency and standardization in the

methodologies used to determine cost.

The dominant driver of health care cost is

the expanding medical technology arena

where new modalities either fill a need for

diagnosis and treatment, or replace older

modalities that are cheaper. Newer technologies have a large impact on health care

spending in the United States because there

are few requirements that effectiveness be

demonstrated before wide national implementation. Newer technologies also have

the potential to increase applications where

therapy might not even be effective.

The Veterans Health Administration research

program offers an ideal home for studying

comparative effectiveness. We are a large

integrated health care system with an electronic medical record, Bar Code Medication

Administration (BCMA) and provider order

entry, strong pharmacy benefit, Technology

Assessment Program (TAP) – and outstanding researchers.

References

1. Smith S, Heffler S, Freeland M. The Next Decade of

Health Spending: A New Outlook. The National

Health Expenditures Projection Team. Health Affairs

(Millwood), 1999 Jul-Aug; 18(4):86-95.

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter

This issue of FORUM focuses on the important topic of Comparative Effectiveness Research (CER). Both clinicians and patients appreciate the limited benchmarks available to inform

clinical decisions and treatment options. Policymakers find

themselves in a similar situation—making health care legislation in an evidence vacuum. For clinicians, patients, and policymakers alike, however, CER has the potential to provide

much needed evidence-based criteria for health care decision-making.

Recently, CER activities have been expanding across the Federal Government. In

March 2009, the U.S. Department of Health and Human Services (HHS) established a 15 member Federal Coordinating Council for Comparative Effectiveness

Research (FCCCER). Supported by funding of approximately $1.1 billion, the FCCCER will help guide, prioritize, and coordinate comparative effectiveness research

across HHS and the Departments of Veterans Affairs and Defense. Joel Kupersmith,

M.D., VA’s Chief Research and Development Officer, represents VA on the council.

In other news, HSR&D gave a warm send off to Shirley Meehan who retired from

VA service on May 1. Dr. David Atkins, QUERI Director, will also serve as Acting

Deputy Director of HSR&D until a new Deputy is named.

And finally, I would like to note that we reviewed 124 proposals in the March

review, of which we expect to fund 32 projects. In addition, we reviewed 30 Career

Development Award applications and we expect to fund seven. Congratulations

to all. Please keep your proposals coming.

Seth A. Eisen, M.D., M.Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service May 2009
VA Office of Research & Development, Health Services Research & Development Service May 2009

Despite great advances in medical knowledge, the effectiveness of many health

services is unknown. Comparative effectiveness research can close this gap and improve

the quality of U.S. health care. The value of

this research is widely appreciated. Effectiveness evaluations are almost universally

employed by public and private health plans

to determine what new technologies they

will cover.

1

Comparative effectiveness research may not

answer all decision makers’ questions, however. An effectiveness study can determine

both benefits and adverse effects of an

intervention, but this does not reveal

whether the health improvement outweighs

the possible harm. Even with clear evidence

that a new test can more effectively detect

disease, other evidence is needed to know if

early detection confers a net benefit. Data

from many sources must be linked.

Using CEA to Extend

Comparative Effectiveness

These types of limitations in comparative

effectiveness research can be overcome by

methods used in Cost-Effectiveness Analysis (CEA).

2

CEA values health outcomes using a measure of morbidity adjusted survival called the

Quality Adjusted Life Year (QALY). This

measure can also be applied to comparative

effectiveness research, to trade off benefits

against harm. The medical decision modeling methods employed in CEA can be used

in comparative effectiveness research, to

link effectiveness findings to studies of

long-term health outcomes.

Despite its versatility, CEA is not nearly as

well regarded as comparative effectiveness

by U.S. decision makers. This may be because they do not understand the uses of

CEA, because they feel that its methods are

unreliable, or because findings have not

been relevant to their particular setting or

time-horizon.

3

Other reasons why CEA may not be used

include political opposition from drug and

device developers, and unwillingness of

Americans to concede that effective but

expensive treatments cannot be provided

if benefits are modest.

As Dr. Almenoff points out, new technology

accounts for much of the increase in health

care costs. CEA can help determine if innovations yield sufficient value to justify their

cost. CEA methods have been standardized

for more than a decade and applied to hundreds of innovations. CEA is widely used in

other countries, where it is among the criteria used to make coverage decisions.

VHA: The Challenge to Lead

in Comparative Effectiveness

Research

The Veterans Health Administration (VHA)

is well positioned to be a U.S. leader in

applying both comparative effectiveness

and cost-effectiveness research. VHA is a

globally budgeted, national system, with

the long-term responsibility for the health

of a well-defined population. Research is

integrated with VHA care. VHA utilization

and cost data are the envy of other health

care plans.

Social value judgements about vulnerable

or especially deserving plan members need

to be incorporated into decisions based on

CEA. This type of review has been important to the acceptance of CEA in other

countries.

4

Veterans are a well-organized constituency

that deserves to participate in VHA coverage decisions.

Response to Commentary

Comparative Effectiveness Research

and Beyond

Paul G. Barnett, Ph.D., VA HSR&D’s Health Economics Resource Center

FORUM — Translating research into quality health care for Veterans 3

Recently, FORUM spoke with Al Perry, Director, VA Central California Health Care

System regarding the challenges facing VHA Senior Leadership Teams in the

field. Perry described five challenges:

1. Finding the most effective among constantly evolving treatment techniques,

programs, equipment, and drugs.

2. Meeting the challenge of newly eligible Priority Group 8s, and of “victims” of

the economic downturn.

3. Delivering health care services to returning OEF/OIF Veterans, particularly

those with mental health care needs and those living in rural areas.

4. Delivering increasingly expensive services under tight budget constraints.

5. Addressing ever increasing expectations for measurable quality and outcomes.

HSR&D research topics of interest to leadership in the field include: provider behavior, comparative technology, inpatient vs. outpatient treatment particularly

for mental health, settings and approaches to women’s health, and solo vs.

team or group treatment.

continued on page 8
The benefits of identifying and treating

asymptomatic Human Immunodeficiency

Virus (HIV)-infected individuals substantially exceed those of early recognition of

most medical conditions. Routine HIV testing is of particular importance to the VA,

the largest provider of HIV services in the

United States. Nevertheless, in the VA, as in

many other health care systems, 50 percent

of HIV-infected patients are diagnosed after

they have developed severe immunological

damage.

Among the deterrents to promoting early

routine HIV testing is that reliance on standard blood tests requires that patients receive their test results at a later date; this can

present a considerable barrier for homeless

and transient patients. To address this barrier, QUERI-HIV/Hepatitis has undertaken

a series of studies to evaluate the utility of

same-day, oral fluid-based HIV rapid testing

programs. One such study, which was conducted in a primary care clinic setting,

demonstrated increased patient satisfaction

and receipt of test results with nurse-based

offer and performance of HIV rapid tests

as opposed to traditional physician-ordered,

blood-based HIV testing.

Economic Impact of HIV Rapid

Testing

To assess the economic impacts of rapid

testing, we conducted two separate complementary Cost-Effectiveness and Business

Case Model (BCM, also referred to as

Budget Impact Analysis) analyses. Whereas

cost-effectiveness analyses consider the

long-term (i.e., over a patient’s lifetime) financial and health impacts of an intervention from a health care system or societal

perspective, BCM analyses evaluate the

near-term financial costs of program implementation.

1

Even for programs that reduce costs (i.e.,

are cost saving), the savings are usually over

a period of many years and the immediate

implementation costs may overshadow

short-term savings. This temporal financial

mismatch is magnified for programs that are

cost-effective rather than cost saving. Consequently, both Cost-Effectiveness and

Business Case Models are necessary to appropriately estimate short-term and longterm financial impact.

Following this paradigm, we first conducted

a cost-effectiveness analysis of the longterm financial and health impacts of nursebased HIV rapid testing as opposed to

physician-ordered traditional blood-based

HIV testing. This evaluation built upon previous analyses that demonstrated that routine blood-based HIV testing is costeffective on a societal basis at the $50,000/

QALY threshold for populations where the

prevalence of undiagnosed HIV infection is

greater than 0.05 percent. In analyses that

considered the time spent for pre-test counseling, test performance and post-test counseling, laboratory supplies, and the care of

persons found to be HIV-infected, we

found that compared with the blood-based

testing, the incremental cost of nurse-based

rapid testing was $10,689/QALY when societal benefits were considered.

2

More recently, we developed a BCM to

compare the financial impact of routinely

offering rapid HIV tests during non-peak

hours in a VA Emergency Department

(ED) versus offering diagnostic testing only

for patients presenting with symptoms suggestive of HIV infection (as is usual ED

practice). We estimated the number of people who would be identified as HIV-infected

through routine rapid testing, the start-up

and maintenance costs of the rapid test program, and diagnostic and treatment costs

for HIV-infected patients identified by rapid

testing. We then compared these costs to

the expenses incurred by patients identified

as being HIV-infected at later stages of disease through routine practice.

Using base case data from a single VA ED,

we found that a rapid test program that

makes use of ED capacity during non-peak

hours was not more costly than usual ED

practice. This result is likely due to the high

costs of care of patients who present with

late stage disease when current practice is

followed. Given that early detection of HIV

and linkage to treatment is associated with

better health outcomes, and that the rapid

test program does not cost more than current practice, this budget impact analysis

provides support for the implementation of

HIV rapid testing programs in VA EDs.

3

Conclusion

Often, long-term cost-effectiveness assessments are used to establish the value of an

initiative such as routine HIV testing. However, even when the long-term value of a

program is clear, the realities of implementation in the near term can create significant

barriers for acceptance. Effective BCM assesses the short-term costs and benefits to

evaluate the consequences of implementing

new initiatives.

References

1. Mauskopf JA, Sullivan SD, Annemans L, et al.

Principles of Good Practice for Budget Impact

Analysis: Report of the ISPOR Task Force on Good

Research Practices - Budget Impact Analysis. Value

Health 2007; 10:336-47.

2. Sanders GD, Anaya H, Asch S et al. Cost Effectiveness

of Rapid HIV Testing with Streamlined Counseling

2007; Sydney, Australia; July 22-25, 2007.

3. Gidwani R, Goetz MB, Needleman J et al. Development of Business Case Methodology Using VA Data:

Implications for QUERI Research Projects. VA

HSR&D Annual Meeting 2009; Baltimore, MD.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service May 2009

Research Highlights

Analysis of the Cost of an HIV Rapid

Testing Initiative

Matthew Bidwell Goetz, M.D., Center of Excellence for the Study of Healthcare

Provider Behavior, VA Greater Los Angeles Healthcare System
VA Office of Research & Development, Health Services Research & Development Service May 2009

Recently, the Department of Defense (DoD)

issued a Rehabilitation Directive, the goal of

which is to return service members with

limb loss from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/

OIF) to pre-injury function and provide them

the option of returning to active duty. To

meet this goal, the DoD Amputee Patient

Care Programs and VA Medical Centers

offer state-of-the-art comprehensive rehabilitation care, including prosthetic care.

VA limb distribution practice allows any

Veteran with limb loss to request and/or receive any prosthetic device if deemed medically appropriate, feasible and/or indicated

according to their functional level. Prosthetic care is one component of a comprehensive rehabilitation care program for

those with major limb loss. As such, it is

crucial to estimate future costs of prosthetic

devices in order to plan appropriately for

effective resource allocation. We conducted

a study of prosthetic costs as part of a

larger research project involving service

members with traumatic limb loss from

Vietnam and OEF/OIF.

In step 1 of the study (see figure), researchers conducted a nationwide survey,

which identified Vietnam and OEF/OIF

service members’ prosthetic history since

limb loss and current assistive-device use. In

step 2, researchers developed a cost matrix

for all upper and lower limb prosthetic costs

and assistive devices, and then categorized

these by level of function using Medicare

costs as the common metric.

In step 3, researchers linked each study

participant’s utilization and function to

the cost matrix to compute individual total

annual costs. In step 4, the study’s expert

panel of VA and DoD rehabilitation

leadership, rehabilitation and prosthetic

specialists, academic and private practice

physicians, prosthetists, researchers, and

service members with limb loss made

recommendations on model parameters in

areas where there is no published data. In

step 5, researchers projected total cumulative prosthetic costs for 5-year, 10-year,

20-year, and lifetime time horizons. We did

this separately for OEF/OIF service members and Vietnam Veterans suffering traumatic limb loss. Type of limb loss was

categorized as isolated lower, isolated upper,

bilateral upper, and multiple limb loss. For

Vietnam and OEF/OIF cohorts, and each

category of limb loss, we used separate costprojection models.

The analysis results in cost distributions for

projections over all time horizons and types

of limb loss. Overall, our model indicates

that for OEF/OIF service members with

isolated lower limb loss, 5-year, 10-year, 20-

year, and lifetime average per-person costs

Research Highlights

Estimating Future Costs of Prosthetic

Devices

David K. Blough, Ph.D., University of Washington, Seattle, Washington,

Sharon Hubbard, M.S., Prosthetics Research Study, Seattle, Washington,

Lynne V. McFarland, Ph.D., and Gayle E. Reiber, M.P.H., Ph.D., both with

VA Puget Sound Health Care System, Seattle, Washington

FORUM — Translating research into quality health care for Veterans 5

continued on page 8

Cost Projection Steps, Vietnam and OEF/OIF Service Members

with Major Traumatic Limb Loss

1. National Survey

Inputs

Study ID:

Conflict

Limb loss level

Prosthetic type

Quantity

Usage

Assistive-device types

Activity level

2. Cost Matrix

Limb loss level

Prosthetic type

Assistive device type

Activity level

Medicare cost is

common metric

3. Current Cost File

Study ID:

Conflict

Activity level

Prosthetic/Assistive type

Quantity

Usage

Medicare cost each

Medicare cost total

Validated by expert

prosthetists

4. Markov Models

Conflict

Limb loss level

Activity level

Prosthetic cost

Transition probabilities

Expert panel inputs

5. Results

Projected 5-, 10-,

20-year, and lifetime

prosthetic costs
Heart failure is a chronic syndrome associated with frequent exacerbations often resulting in hospitalization and death.

1 Readmission for heart failure occurs within 30 days

following 20 percent of discharges from

the VA system with similar rates in the

Medicare health care system. The high rate

of hospitalization has led to cost estimates

of over $37 billion for heart failure care in

the United States for 2009.

2

Given the high cost and morbidity associated with heart failure hospitalization,

recent research has focused on preventing

admissions and readmissions in particular.

Accordingly, preventing readmissions is

now a focus of heart failure studies including studies related to comparative effectiveness. The rate of heart failure readmission

has been discussed as a possible performance measure by the VA, Joint Commission,

and Centers for Medicare and Medicaid

Services. The latter plans to release to the

general public risk-adjusted 30-day heart

failure readmission rates for all nongovernment hospitals in summer 2009.

A heart failure readmission may be defined

in multiple ways. It can be the primary cause

of admission (coded as a principal diagnosis),

a contributing factor (coded as one of the

secondary diagnoses), or it may be unrelated

to heart failure but occurring within a certain

time period following a heart failure discharge. Using the principal diagnosis criteria,

readmission occurs in 10 percent of patients

at 30 days following discharge compared to

20 percent if one defines heart failure as a

primary or secondary diagnosis. An admission for any cause occurs in approximately

25 percent of heart failure patients at 30

days following discharge.

Readmission as a Measure of

Health Outcome and Quality of

Care

While a heart failure readmission clearly

increases cost, its use as a measure of health

outcome is less clear. One of the principles

of care coordination is delivering the optimal care in the optimal setting. Occasionally

this setting is in the hospital, and trying to

keep some patients out of the hospital may

result in inferior care.

If readmission is a valid measure of the

quality of heart failure care, it should satisfy

several criteria. First, a significant fraction

of readmissions should be due to preventable causes. Unfortunately, heart failure as

the primary diagnosis accounts for only

about a third of readmissions. Half of all

readmissions are due to non-cardiac causes

(as the principal diagnosis), and the remainder of readmissions (one sixth) is due to

non-heart failure cardiac causes.

Second, one should be able to distinguish

elective from non-elective readmissions.

Presumably the non-elective admissions are

more indicative of quality of care. Patients

may be readmitted for elective device placement (e.g. defibrillator or resynchronization

therapy) and the diagnosis may be coded as

heart failure.

Third, all relevant admissions should be

captured. Often, readmissions for Veterans

are not captured using VA records because

many Veterans receive cardiology care for

heart failure outside of the VA system. This

dual use may bias results of comparative effectiveness and cost-effectiveness studies.

Finally, variation in case mix should be minimal or measurable so that appropriate adjustments can be made. VA hospitals show

moderate differences (e.g. age, income) in

the patient population they admit with heart

failure and such differences are likely to impact readmission rates.

Heart Failure Readmissions and

Cost-Effectiveness

Since heart failure admissions account for

up to 80 percent of the cost of heart failure

care, knowing the impact on heart failure

admissions is important for all cost-effectiveness analyses of heart failure interventions. As a general rule, any treatment that

reduces heart failure hospitalizations (or

mortality) is likely to be cost-effective compared to other accepted health interventions. Many disease management programs

have reduced heart failure readmissions,

though recent trials have had difficulty

showing significant reductions, perhaps due

to the improvement in usual care for heart

failure.

Data from VA, non-VA U.S., and non-U.S.

countries have demonstrated that as recommended medication use has increased so has

survival following a hospitalization for heart

failure. Unfortunately, readmission rates

have not similarly improved in the VA and

data from the U.S. National Hospital Discharge Survey indicate a slight increase in

hospitalization rates from 1995-2004.

While a heart failure admission is a clear

contributor to the cost of care, using it as

an outcome or quality measure is challenging. Cost-effectiveness and comparative

effectiveness studies should not limit their

outcome assessments to readmission when

evaluating heart failure treatments.

References

1. Hunt SA, Abraham WT, et al. 2009 Focused Update

Incorporated Into the ACC/AHA 2005 Guidelines for

the Diagnosis and Management of Heart Failure in

Adults. A Report of the American College of Cardiology Foundation/American Heart Association Task

Force on Practice Guidelines. Circulation. Mar 26

2009.

2. Lloyd-Jones D, Adams R, et al. Heart Disease and

Stroke Statistics – 2009 Update: A Report from the

American Heart Association Statistics Committee and

Stroke Statistics Subcommittee. Circulation

2009;119(3):480-6.

FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service May 2009

Research Highlights

Readmission for Heart Failure

Paul Heidenreich M.D., M.S., Chronic Heart Failure QUERI, VA Palo Alto

Health Care System
VA Office of Research & Development, Health Services Research & Development Service May 2009

“Defining Optimal Care: Balancing Quality,

Cost, and Patient Preferences” was the

theme of the 27th VA Health Services Research and Development Service (HSR&D)

National Meeting held February 11-13, 2009

in Baltimore. The Center for Clinical Management Research – HSR&D’s Center of

Excellence in Ann Arbor, Mich. served as

this year’s meeting host. More than 660

policymakers, clinicians, and researchers

attended the meeting where 82 papers, 18

workshops, and 125 posters were presented

on vital health care issues, such as chronic

illness, vulnerable populations, mental health,

economic analysis, and long-term care.

In addition to the exceptional peer-reviewed

research presented over the course of the

meeting, the meeting offered a day devoted

to HSR&D’s Career Development Program.

One of HSR&D’s greatest strengths is the

high caliber of its investigators. Supporting

the development of investigators in the

early, mid- and advanced stages of their careers is a high priority. The meeting also offered several special interest group sessions

and breakfast sessions on topics ranging

from ways to improve health care for Veterans living in rural settings, to strategies for

improving VA/DoD research collaborations, to genomics.

A special plenary paper session highlighted

the five top scoring abstracts submitted to

the meeting. The topics of these five presentations were as follows:

■ A Cost-Benefit Analysis of Higher Medication Copayments in Veterans with Schizophrenia by John Zeber, Ph.D.,

■ Case/Self Management in COPD: A

Randomized Trial by Kathryn Rice, M.D.,

■ AUDIT-C Alcohol Misuse Screening

and Post-operative Complications: A Cohort Study of Men Undergoing Major Surgery in VA by Katharine Bradley, M.D.,

M.P.H.,

■ Impact of Novel Patient Educational

Booklet on Colonoscopy Preparation in

Veterans by Brennan Spiegel, M.D.,

M.S.H.S., and

■ Assessing VA Mental Health Intensive

Case Management: Program Effects on

Mental Health Services Use by Eric Slade,

Ph.D.

Other meeting highlights included an

address by then VA Under Secretary for

Health Michael Kussman, M.D., M.S.,

MACP, who also presented two of VHA’s

highest honors. H. Gilbert Welch, M.D.,

M.P.H. received the Under Secretary’s

Award for Outstanding Achievement in

Health Services Research. Part of the

White River Junction VA Medical Center

in Vermont, Dr. Welch has made significant

contributions in the areas of technology

assessment, health policy, and understanding the benefits and harms of early diagnosis. The other honor was presented to Dr.

Shirley Meehan (see box).

VA’s Chief Research and Development Officer, Dr. Joel Kupersmith, and HSR&D Director, Dr. Seth Eisen, each spoke about

current VA research priorities, such as the care

of complex chronic conditions and postdeployment health. The keynote address was

provided by Nicole Lurie, M.D., M.S.P.H.,

Director of Population Health and Health

Disparities and Co-Director of the Center

for Domestic and International Health Security at the RAND Corporation, who spoke

about the rapidly changing health care environment. Dr. Lurie’s thoughts on the topic

were of particular interest given her recent

role as a member of the Obama Transition

Project’s Agency Review Working Group,

for which she assessed the U.S. Department

of Health and Human Services.

Meeting abstracts are available at www. hsrd.

research.va.gov/meetings/2009/abstracts.

cfm. Slide presentations are available on the

VA Intranet only at vaww.hsrd.research.va.

gov/meetings/2009/presentations.cfm

Highlights of the 2009 HSR&D

National Meeting

FORUM — Translating research into quality health care for Veterans 7

Meehan Receives VA’s Exemplary Service Award

Dr. Kussman presented the highest honor bestowed by the Office of the Under Secretary – VA’s Exemplary Service Award –

to Shirley Meehan, M.B.A., Ph.D., HSR&D Deputy Director. Dr.

Meehan received the award at the 2009 HSR&D National Meeting.

During her 38-year tenure with VA, Dr. Meehan contributed

in many ways to improving the health and health care of

Veterans. She began working within research in the 1970s, helping to build the

infrastructure of the health services research program. Most of us know her best

as Deputy Director of HSR&D, a position she has held since 1992. In the Deputy

role, she helped to enhance the HSR&D program by strengthening the merit

review process, contributing to the development of the HSR&D Centers of

Excellence, shaping the Career Development Award Program and more recently,

helping construct the Evidence Synthesis Program. In addition, she helped shape

the HSR&D research portfolios and guided the hiring and training of the excellent Scientific Program Managers who currently oversee them. Dr. Meehan

retired from VA on May 1, 2009.

Several new Special Interest Groups (SIG)

have formed within HSR&D. See information about joining or starting a new SIG at

www.hsrd.research.va.gov/for_researchers/sig/
Researchers must do a better job of learning the needs of health care decision makers. (For an example, see the concerns of

medical center director Alan Perry in the

side bar). We must clearly articulate our

methods. Our studies must be more relevant and timely. We can shorten our response time by developing models of care

for major diseases in anticipation of future

coverage decisions.

Every household understands that resources

are limited and that choices must trade off

value against cost. Comparative effectiveness is just the first step on a path to greater

efficiency. Cost-effectiveness analysis can

help us get the best possible outcomes from

the available health care budget.

References

1. Garber, AM. Evidence-based Coverage Policy.

Health Affairs (Millwood), 2001; 20(5): p. 62-82.

2. Russell, LB. The Methodologic Partnership of

Effectiveness Reviews and Cost-effectiveness Analysis.

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(3 Suppl): p. 10-2.

3. Neumann, PJ. Why Don’t Americans Use Costeffectiveness Analysis? American Journal of Managed

Care, 2004; 10(5): p. 308-12.

4. Gold, MR, Sofaer S, and Siegelberg T. Medicare and

Cost-effectiveness Analysis: Time to Ask the Taxpayers. Health Affairs (Millwood), 2007; 26(5):

p. 1399-406.

FORUM — Translating research into quality health care for Veterans 8

Response to Commentary

continued from page 3

Research Highlights

continued from page 5

David Atkins, M.D., M.P.H.,

Acting Deputy Director of

HSR&D and QUERI Director

VA Central Office, Washington DC

Peter L. Almenoff, M.D.,

FCCP, Assistant Deputy

Under Secretary for Health

for Quality and Safety, VA

Central Office, Washington

DC

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient

Services & Chief Nurse

Executive, VA New York

Harbor Health Care System,

New York, NY

Martin P. Charns, D.B.A.,

Director, VA HSR&D Center

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc.,

Director, HSR&D

VA Central Office, Washington, DC

Joseph Francis, M.D., M.P.H.,

Acting Chief Quality and

Performance Officer, VA Central Office, Washington DC

Rodney A. Hayward, M.D.,

Co-Director, VA HSR&D

Center of Excellence,

Ann Arbor, MI

Alan S. Perry, M.H.A.,

FACHE, Director, VA

Central California Health

Care System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

are $229,000, $474,000, $856,000 and $1.5

million, respectively. The corresponding costs

for the Vietnam group were estimated to be

$82,251, $167,848, $281,234, and $342,716,

respectively. The mean costs for the OEF/OIF

group are 2.8 fold to 6.2 fold higher than the

corresponding costs for the Vietnam group.

This reflects higher costs for the more technologically advanced prostheses, use of

multiple artificial limbs, and fewer service

members abandoning prosthetic devices.

The standard deviations of costs steadily increase as the length of the projected time

horizon increases for both groups and all

types of limb loss, thus estimating costs

over longer periods has greater uncertainty.

Based on our findings we recommend a uniform standard of rehabilitation and prosthetic care for service members with limb

loss cared for by VA directly or through VA

contracts. A uniform standard for coverage

of prosthetic and assistive devices as part

of their overall rehabilitation care will assist

veterans with major traumatic limb loss.

The study provided VA clinicians and policy

makers with information on the health, combat injuries, function, quality of life, prostheticdevice utilization, replacement, abandonment,

and satisfaction of these service members.

The results of this study will assist VA clinicians and decision makers in planning for

future care of service members with limb loss.

Findings from the larger study include four

editorials, 10 manuscripts and the expert

panel’s clinical and research recommendations for care of service members with limb

loss. Complete study findings are slated for a

special issue of the Journal of Rehabilitation

Research and Development later this year.