The idea of screening is seductive—isn’t it

always better to find things early, rather than

late? Screening, defined as testing for a condition when the person has no recognized signs

or symptoms of that condition, is widespread

and popular. Patients often want screening tests

done and clinicians, for a variety of reasons,

want to provide them. The purpose of screening, however, is not only to detect a condition

but also to help people live better or longer.

Early detection of disease by itself is insufficient to justify a screening program. Screening

must also demonstrate that people live better

or longer as a result of earlier detection and

subsequent treatment. 

Weighing the Benefits

Screening is not a single test but rather a 

cascade of events that can lead to either benefits

or harms. Potential benefits, living better or

longer, are usually experienced some years

after screening. Potential harms, including the

effects of false-positive or false-negative screening tests and problems that result from overdiagnosis and overtreatment, are usually suffered soon after screening. Because screening

programs may lead to either net benefit or net

harm, decision makers must carefully evaluate

proposed programs. 

Among the factors to be considered, accuracy

of the screening test is less critical than effectiveness of early treatment. For a screening

program to improve health outcomes, it must

include a treatment that is not only effective

but that is also more effective if applied earlier

than later. If the treatment works just as well

later in the course of the disease, screening fo

early detection is not necessary.

Screening for a number of conditions has bee

shown to meet these criteria. These condition

include: breast, cervical, and colorectal cancer;

hypertension, dyslipidemia, and abdominal

aortic aneurysm; infectious diseases including

HIV and several other sexually transmitted

infections in certain populations; obesity, diabetes, and osteoporosis in selected groups; an

depression, alcohol misuse, and tobacco use. 

Who Should be Screened? 

Recommendations for specific screening tests

vary by age, gender, and other risk factors.

Groups targeted for screening are those in whom

the prevalence of the disease is substantial enoug

to warrant attention. The balance between ben

efits and harms may be different in people wit

different risk factors. For example, consider

screening for abdominal aortic aneurysm by

ultrasonography, which was recently recommended for men age 65 to 75 who have ever

smoked by the U.S. Preventive Services Task

Force and endorsed by the VHA Office of Qualit

and Performance.1, 2 Although the condition doe

occur in women and in men who have never

smoked, the prevalence is greatest among

older men who have smoked. For this specific

group only, the magnitude of benefits likely

outweighs the known harms of screening and

treatment (surgical morbidity and mortality). 

FORUM

Screening: Balancing the Benefits and Harms

By Linda Kinsinger, M.D., M.P.H., VA National Center for Health Promotion and Disease

Prevention, Office of Patient Care Services 

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlights 4

Organizational Profile 6

HSR&D National Meeting 7

May 2006 VA Health Services Research & Development Service

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

translating research 

into quality health care

for veterans

continued on page 
2 ■ Forum/May 2006

Director’s Letter Upper age limits for screening are important

to consider. For most conditions, any life

extension from screening does not occur

immediately after screening but rather some

years in the future. Thus, to realize the benefit

from screening, one must live a certain period

into the future and be well enough to withstand the confirmatory tests and treatment

that may result from a positive screening test.

As people age, however, the risk of dying

from other conditions may be higher than

the risk of dying from the screened condition. Or, their general health may be such

that screening, including follow-up tests

and treatment, would not be appropriate. 

Health care providers need to take into

account a person’s estimated life expectancy

and overall health status in the decision about

screening. An abstract presented at the 2006

HSR&D National Meeting reported that 27

percent of men age 90 and older seen in

VA medical facilities had a PSA test for

prostate cancer screening in 2003 and 

that screening for men age 70 and older 

did not vary by overall health status.3 Given

that the benefits of PSA screening have 

not been definitely proven for men in any

age group, screening men in their nineties

or younger men with limited life expectancy

can result only in harms and wasted effort

and costs.

Screening in VA

Screening programs in VA should not only

emphasize recommendations that have the

most favorable benefits-to-harms balance

With 185 plenary sessions, exhibits, workshops, and poster sessions, our Health

Services Research & Development Service

(HSR&D) National Meeting demonstrated

the breadth of HSR&D research and its

importance to veterans’ healthcare. A

highlight was the presentation of the 

Under Secretary’s Award for Outstanding

Achievement in Health Services Research to

Dr. Eugene Oddone. (See pg. 7 for details).

The quantity and quality of HSR&D work

continues to be impressive. In March, the

Scientific Merit Review Board reviewed 145

proposals, of which we hope to fund 37 by

Fiscal Year 2007. This brings the funding

average over the last three review cycles

up to approximately 22 percent. Excellent

proposals that are particularly responsive

to HSR&D and Office of Research and

Development solicitations will receive priority funding. We were pleased to receive

many such projects this last round,

including projects focused on issues critical to Operation Enduring Freedom and

Operation Iraqi Freedom (OEF/OIF) veterans. Other highly scored InvestigatorInitiated Research proposals will be funded as applicants complete any conditions

such as just-in-time institutional review

board documentation and as funds

become available. In the Quality

Enhancement Research Initiative (QUERI)

program, three (27 percent) ServiceDirected Project proposals reviewed

between August 2005 and March 2006

were funded. HSR&D will continue to

emphasize research that addresses the

health and care of veterans. In addition,

we are working to streamline the “intent

to submit” and proposal process by developing electronic submissions.

The search for a new Director of HSR&D

is underway. While it continues to be

rewarding and challenging to serve as

Acting Director of HSR&D, I look forward

to welcoming a new Director in the near

future. 

Shirley Meehan, M.B.A., Ph.D.

Acting Director, HSR&D

for individuals, but should also focus on

those recommendations that will have the

greatest impact at the population level. The

demographics of the VA patient population—largely older men—suggest that

screening programs focused on risk factors

for heart disease (blood pressure, lipids,

and smoking) will have the greatest impact

on helping veterans live better or longer. 

For women, the traditional focus has been

on breast and cervical cancer screening

programs. VA providers must also remember that, just as in men, heart disease is th

leading cause of mortality in women, so

focusing on screening and interventions

for those cardiovascular risk factors is

equally important for women. Screening

for colorectal cancer and depression is also

important in helping veterans live better

and longer. While not ignoring other recommended screening tests, increasing

these high priority services will lead to the

largest improvements in health outcomes

for both men and women. 

Shared decision making between patients

and providers is a critical element in the

screening process. We need to learn more

about effective and comfortable ways for

patients and clinicians to engage in this

activity. The research agenda around

screening—what tests to do, for whom, an

how to get them done—remains full. ■

References

1 U.S. Preventive Services Task Force.

Screening for Abdominal Aortic Aneurysm

2005. Available at www.ahrq.gov/clinic/

uspstf05/aaascr/aaars.pdf 

2 Evidence-based Practice Work Group,

Office of Quality and Performance.

Screening for Abdominal Aortic Aneurysm

2005. Available at www.oqp.med.va.gov/cpg

Publications/USPSTF/AAA%20Memo.doc 

3 Walter L, Bertenthal D. Relationship of

Health Status and Screening PSA among

Elderly Veterans. Poster presented at the

Health Services Research and Developmen

National Meeting 2006, Arlington, VA.

“Early detection of disease by itself is

insufficient to justify a screening

program. Screening must also

demonstrate that people live better

or longer as a result of earlier

detection and subsequent treatment.”
Forum/May 2006 ■ 

Response to Commentary

Individualized Screening

By Sandeep Vijan, M.D., M.S., HSR&D Center for Practice Management & Outcomes

Research, Ann Arbor, MI 

The U.S. health care system is in the midst

of a gradual shift away from treatment of

acute conditions to prevention of disease.

An emphasis on screening is a major part

of this trend. The driving force behind this

shift seems to be common sense; early

detection, leading to early treatment, should

lead to better health. As straightforward as

this seems, however, human health is

invariably complex and screening is rarely

without unanticipated consequences. 

Screening Decisions Are Complex

In her commentary, Dr. Kinsinger notes

that balancing both the harms and the ultimate benefits of screening (ideally measured in life expectancy and quality of life)

is necessary in order to make appropriate

screening decisions. Adding to the complexity of decision-making is a myriad of

conditions that may be amenable to

screening, a variety of screening tests, and

questions about who, when, and how often

to screen. In most cases, we have only limited answers to these questions.

Organizations such as VA and the U.S.

Preventive Services Task Force have

reviewed the existing screening literature

carefully and have recommended screening for only the subset of conditions pointed out in Dr. Kinsinger’s commentary.1 In

these situations, either randomized trials

or overwhelming observational evidence

have shown that, on average, there are benefits to screening. Unfortunately, trials are

often limited in inclusion criteria and

scope, and we often must extrapolate

screening decisions beyond those included

in trials. Further, only limited screening

approaches have been tested in most trials;

few studies, for example, compare various

intervals for screening, or examine competing screening options. 

The variability in test options, intervals, and

accuracy is important to consider. From a

health system perspective, inaccurate

screening tests and overuse of screening

are problematic. In a fixed resource system

such as VA, false positives consume limited

resources, may delay appropriate evaluation

of other patients, and lead to potential

harms associated with follow-up testing. 

The limitations of the current literature on

screening make applying trial evidence to

individual patients challenging, and few trials

have been examined in ways that help us

evaluate individual risks and benefits.2 At

present, we are almost certainly overusing

screening in patients unlikely to benefit and

underusing it in those who are likely to

Screening in the Elderly

Sandeep Vijan, M.D., M.S.

A common question about screening is:

“When do you stop?” The answers to this

question seem to vary with the disease

under consideration and the type of test

being performed.

The vast majority of benefit from cancer

screening is achieved before age 75 for

breast cancer, age 80 for colon cancer,

and age 65 for cervical cancer.1 However,

when disease risk increases with age, the

yield of screening tests is higher in the

elderly, and screening may be reasonable.

Some guidelines are clear on when to

stop screening. Cervical cancer screening

is not recommended past age 65.

Mammography is probably effective and

cost-effective for some older women, and

should be considered in those without

significant comorbidities. Fewer data are

available to guide us on when to stop colorectal cancer screening. As a rule of

thumb, if the patient has a life expectancy

of less than 10 years, then screening with

endoscopy is probably not warranted. 

A few general guidelines apply. Clinicians

need to be aware of the nature of the disease when counseling patients; diseases

that are less prevalent in the elderly (e.g.,

cervical cancer) generally do not warrant

screening. Screening for diseases with

higher prevalence should be considered,

but the likelihood of benefit and harm

must be taken into account. For example,

in the typical elderly VA patient with significant comorbidities, competing risks of

death will significantly limit the benefits

and amplify the harms of screening. Most

importantly, patient preferences must

play a role in all screening discussions.

Reference

1 Rich JS, Black WC. When should we

stop screening? Effective Clinical Practice

2000; 3:78-84.

continued on page 8

“Adding to the complexity of decisionmaking is a myriad of conditions that

may be amenable to screening, a

variety of screening tests, and questions about who, when, and how

often to screen. In most cases, we

have only limited answers to these

questions.”
As treatments for mental disorders have

become more effective and acceptable to

patients, the case for screening and early

recognition of these disorders is strengthened. Early recognition raises the possibility

of preventing the development of other

mental and substance use disorders which

so often are co-occurring. Much research

has focused on development and validity

testing of brief screening instruments that

can detect risk for disorders such as depression, post traumatic stress disorder (PTSD)

and other anxiety disorders, and substance

use disorders (SUDs). VA clinical practice

guidelines recommend that all patients be

screened for depression, alcohol misuse,

and PTSD on the initial visit and annually. 

Early Intervention Needed 

Two recent developments have heightened

attention to screening and prevention of

mental disorders within VA. First, substantial proportions of returning OEF/OIF veterans are likely to need mental health care,

and early intervention and treatment could

improve long-term outcomes. VA implemented a national clinical reminder for postdeployment screening that prompts providers

to administer the Primary Care PTSD screen,

the AUDIT-C for alcohol misuse, and the

Patient Health Questionnaire-2 for depression. The current emphasis on PTSD

screening is needed, as almost half of patients

with a research diagnosis of PTSD did not

have this diagnosis noted in the medical

record by their primary care provider.1

Research Highlights

Screening for Mental Health and Substance Use

Disorders

By Richard R. Owen, M.D., Center for Mental Healthcare & Outcomes Research, Central

Arkansas Veterans Healthcare System, Kathryn M. Magruder, Ph.D., M.P.H., Ralph H.

Johnson VAMC, and Daniel R. Kivlahan, Ph.D., Substance Use Disorders QUERI, VA Puget

Sound Health Care System

The second development is the report of

the President’s New Freedom Commission

on Mental Health and the subsequent development of the VA Comprehensive Mental

Health Strategic Plan. This document calls

for improved access to mental health care in

VA and recommends screening for cooccurring mental and substance use disorders and linkage with treatment strategies. 

While there are a number of screening measures with sound psychometric properties,

relatively little is known about optimal

implementation of such measures in VA.

Annual screening of the entire population

for mental health disorders such as depression is unlikely to be cost-effective.

Research using FY2002 External Peer

Review Program (EPRP) data on depression

screening found that, while 8.8 percent of

cases screened positive, only about half had

further assessment documented. Only 1.1

percent of cases screened received a new

depression diagnosis.2 Furthermore,

patients that were more likely to screen positive (i.e., those who are younger, unmarried, or have greater medical comorbidity)

were less likely to be screened. These findings suggest that improved implementation

of depression screening and assessment

would result in higher detection rates.

Targeted screening of high-risk populations

(e.g., OEF/OIF veterans for PTSD, depression, and SUDs; pain patients for depression; PTSD patients for SUDs) is likely to

be the most cost-effective approach to

improving recognition of these disorders;

4 ■ Forum/May 2006

however, researchers must assess the feasibility and cost-effectiveness of these

approaches in routine care settings. 

New Approaches to Assessment and

Treatment

HSR&D investigators have developed and

tested approaches aimed at improving

assessment and treatment of mental health

disorders. For example, David Oslin and

colleagues have developed and tested a

“behavioral health laboratory” to improve

diagnostic work-up as well as follow-up

monitoring. Implementation of an evidence-based collaborative care model for

depression called “TIDES” (Translating

Initiatives in Depression into Effective

Solutions) is underway in four VISNs as

part of an HSR&D-funded project led by

Lisa Rubenstein and Ed Chaney. John

Fortney and colleagues have developed and

tested a similar model of depression care

that includes telemedicine in rural

Community Based Outpatient Clinics. Also

a current HSR&D study led by Kathy

Bradley will evaluate the association of

AUDIT-C scores with a range of health out

comes as a way to help “calibrate” the risks

associated with alcohol misuse.

More research is needed to identify effectiv

and efficient screening approaches. With a

new cohort of veterans who may be more

amenable to mental health treatments, VA

should not miss the opportunity to implement effective screening and follow up. ■

References

1 Magruder KM, Frueh BC, Knapp RG, et

al. Prevalence of posttraumatic stress disor

der in VA primary care clinics. General

Hospital Psychiatry 2005; 27:169-79.

2 Desai MM, Rosenheck RA, Craig TJ.

Case-finding for depression among medica

outpatients in the Veterans Health

Administration. Medical Care 2006; 44:175

81. 
Forum/May 2006 ■ 

Screening for a disease refers to testing

individuals who are asymptomatic and are

therefore unaware of whether they have the

disease. The rationale for screening is that,

for some diseases, early treatment is more

effective than is treatment offered later in

the course of the disease. For example,

screening and early treatment for breast

and colon cancer lead to better outcomes.

Screening for an infectious disease offers a

second potential benefit—reduced disease

transmission. For screening to help reduce

disease transmission, either treatment or

changes in behavior must reduce the likelihood of transmission. If screening for a 

disease provides benefits by making early

treatment possible, reducing transmission

to others, or both, then there is the remaining question of whether these benefits 

justify the costs of screening. 

HIV Screening in VA

VA is the largest provider of HIV care in

the United States, with close to 19,000

patients in care. HIV is a strong candidate

for screening. First, the weight of evidence

indicates that treatment given earlier in the

course of HIV does lead to better outcomes

when compared to treatment received 

during advanced stages of the disease.

Second, HIV transmission can be reduced

if infected individuals take steps to reduce

risk behaviors, such as unprotected sex or

needle sharing. 

The importance of reducing transmission is

highlighted by estimates from the Centers

The Effectiveness and Cost Effectiveness of

Screening for HIV

By Douglas K. Owens, M.D., M.S., VA Palo Alto Health Care System and the Center for

Primary Care and Outcomes Research, Stanford University

for Disease Control and Prevention (CDC),

indicating that as many as 20,000 new HIV

infections annually can be attributed to people who are unaware of their HIV-positive 

status. Finally, evidence from within VA 

and elsewhere suggests that many patients

are diagnosed with HIV late in the course 

of disease, when the opportunity for preventing adverse outcomes has been markedly

diminished.

As part of the HIV QUERI, we undertook a

study to determine whether screening for

HIV is effective and cost effective. We used

a mathematical model to estimate the benefit

of screening to the individual identified as

having HIV, the benefit from reduced HIV

transmission, and the cost of screening.1

We also estimated the cost effectiveness of

screening.

We found that when individuals were 

identified through screening as being HIVpositive, early treatment resulted in an additional 1.5 years of life expectancy compared

to those individuals for whom treatment

began later, when they became symptomatic

from HIV. This comparison indicates a sizeable increase in life expectancy, and reflects

the success of current antiretroviral therapy

in reducing mortality from HIV. We also

found that the benefit from reduced transmission increased the total benefit of

screening by about 40 percent, a substantial

increase. This finding highlights an important public health benefit from screening. 

Finally, we found that screening was cost

effective and compared favorably to the cost

effectiveness of other screening and treatment interventions for HIV and other diseases. A cost-effectiveness analysis done

independently by a highly experienced team

from Yale University and Harvard University

came to similar conclusions about the cost

effectiveness of screening.2

Cost Effectiveness of Screening

A key policy question is which populations

should be screened? One of the important

determinants of the cost effectiveness of

screening is the prevalence of HIV infection. Prior screening guidelines from the

CDC have recommended screening in pop

ulations in which the prevalence of HIV 

is 1 percent or greater. Our analysis indicated

that screening would be cost effective even

when the prevalence of undiagnosed HIV

was 0.05 percent, twenty times lower than

the CDC threshold. The implication of this

finding is that screening should be conduc

ed in the vast majority of health care settings. The CDC is currently revising its

screening guideline.

The evidence is clear that people with HIV

are being diagnosed late in the course of

disease in the United States. The current

system of identifying HIV disease is seriously deficient. For a reasonable investmen

of health care resources, screening for HIV

offers substantial benefit both to the individual who is identified and to the community from reduced transmission of HIV. ■

References

1 Sanders GD, Bayoumi AM, Sundaram V,

et al. Cost-Effectiveness of Screening for

HIV in the Era of Highly Active

Antiretroviral Therapy. New England Journa

of Medicine 2005; 352:570-85.

2 Paltiel AD, Weinstein MC, Kimmel AD, e

al. Expanded Screening for HIV in the

United States—An Analysis of CostEffectiveness. New England Journal of

Medicine 2005; 352:586-95.
Organizational Profile

The Colorectal Cancer Quality Enhancement

Research Initiative

By Melissa Partin, Ph.D., CRC QUERI, Minneapolis VA Medical Center

6 ■ Forum/May 2006

The Colorectal Cancer QUERI (CRC QUERI)

is one of 10 VA HSR&D QUERI centers

working to improve the care of veterans by

increasing the rapid implementation of evidence-based best practices. The specific mission of the CRC QUERI is to promote the

translation of research discoveries and innovations into patient care and systems

improvements in order to reduce the incidence, late detection, suffering, and mortality

from colorectal cancers among all veterans. 

Partnerships—A Key Strategy

Effective implementation and system change

requires alignment of diverse parties within

the organization. Several strategies have

proven useful in developing the alignment

necessary to carry out our mission:

■ We have developed partnerships with

numerous operations and policy leaders,

VISN leadership, and frontline clinic staff;

■ We are actively forging a community of

practice that is inclusive of researchers,

management, and clinicians; and

■ We are applying the six-step QUERI

process within a rigorous, conceptuallydriven framework.

Partnerships with operations and policy

leaders pervade all aspects of CRC QUERI

activities. Our executive committee brings a

diverse group of researchers together with

representatives of the Office of Quality and

Performance (OQP), Patient Care Services

(PCS), and VISN-level Chief Medical Officers

(CMOs). This approach assures leadership a

voice in the QUERI agenda, priorities, and

strategic plan. Members of the CRC QUERI

executive committee bring the voice of

research into the policy arena by sitting on

key policy committees, including the Gastrointestinal Field Advisory Group, the EvidenceBased Practices Workgroup, and the National

Performance Measurement Workgroup. 

CRC QUERI also partners with non-VA

leadership through its relationship with the

National Cancer Institute’s Quality Cancer

Care Committee (QCCC). The QCCC is not

only a dissemination vehicle for the CRC

QUERI but also allows us to improve care

for veterans by applying lessons learned by

other federal agencies such as the Centers

for Medicare and Medicaid Services, Health

Resources and Services Administrations,

Indian Health Service, and Centers for

Disease Control and Prevention.

We partner with national and VISN leadership and frontline clinic staff on specific

projects, most recently the Colorectal Cancer

Care Collaborative (C4). This ground-breaking

work is a partnership between OQP, QUERI

and the Office of the Deputy Under Secretary

for Health for Operations and Management

(represented by the Advance Clinic Access

program). We are working with twenty-one

quality improvement teams, in one facility

per VISN, to improve the timeliness and

quality of diagnosis and treatment of colorectal cancer. Phase I of the C4 project,

addressing screening and diagnosis, is 

currently underway and teams are in the

process of implementing targeted quality

improvement interventions. 

The tools, techniques, and insights that

emerge from these efforts are being catalogued and shared within the collaborative

through a web-based “tools warehouse.”

Best practices will eventually be made available to the entire VA. Phase II will focus on

colorectal cancer care. We will examine var

ations in care and describe the types of care

provided for veterans. Through these efforts

a powerful alignment of VISN-level and

frontline staff, policy, operations, and research

is transforming VA practice in the area of

colorectal cancer early detection and treatment

We are sustaining our various partnerships

by creating a community of practice. The

CRC QUERI has three principle ways of

bringing our community together. The 

CRC QUERI Affiliate Forum is a quarterly

newsletter covering a variety of research

issues. The Clinical Brief is a letter to clinicians that provides detailed information on

a single patient care issue each quarter.

And, the Cyber seminar series brings clinicians, management, and researchers togethe

to discuss findings presented by leaders in

the field of colorectal cancer. 

The CRC QUERI approach is characterized

by systems thinking. At each step in the

QUERI process, we consider how patient,

provider, and organizational factors interact. We conduct thorough, but rapid, needs

assessments to understand clinical problems and the needs of management and

clinicians. We have found that “one size

does not fit all” in the VA and that problems that appear similar on the surface ma

require different action across facilities.

For programs to be adopted and sustained

in the field, we need to consider the implementation system that is made up of change

agents (such as QUERI, Advance Clinic

Access, OQP), operations and management,

and frontline clinical staff and providers. 

A constant dialogue is critical so that CRC

QUERI continues to improve and to reflect

the state of the art in knowledge, organizational values and priorities, and the real worl

constraints encountered in medical care. ■

For more information or to be added to our

email list(s), please contact Adam Powell at

Adam.Powell@va.gov.
Forum/May 2006 ■ 

More than 500 researchers, clinicians, and

policy makers participated in VA HSR&D’s

24th National Meeting held February 16-17,

2006 in Arlington, VA. The meeting, with

the theme “Implementing Equity: Making

Research Work for Diverse Veteran

Populations,” focused on issues vital to

improving health care equity. With 185 

plenary sessions, exhibits, workshops, 

and poster sessions, the conference provided

a unique opportunity for discussion, 

collaboration, and development of strategies

to improve the care of our diverse veteran

population.

Hosted by HSR&D’s Center for Health

Equity Research and Promotion (Pittsburgh

and Philadelphia), the meeting highlighted

a range of issues, including disparities in

medical procedures, telemedicine-based 

collaborative care to reduce rural disparities,

and racial differences in attitudes toward

innovative medical technology. Researchers

also addressed chronic diseases and other

health care issues that affect many veterans,

including prostate cancer, HIV, hypertension, mental health, vocational rehabilitation, women’s health, and the health concerns of elderly veterans.

Highlights

Health policy expert Uwe Reinhardt, Ph.D.

and his son, Captain (USMC) Mark Cheng

Reinhardt gave an inspiring keynote

address, “Opportunities and Challenges for

VA Health Care: Perspectives from a Health

Economist and a Combat Veteran.” Captain

Reinhardt recently returned from duty in

Iraq and Afghanistan and shared his 

personal story of how he was wounded

when an improvised explosive device hit 

his Humvee. He praised the care he received,

describing the efforts of the initial field

trauma team that stabilized him, his transfer

to a hospital in Germany, and then, finally,

his journey home. In his remarks, Captain

Reinhardt discussed the needs military men

and women face when transitioning from

soldier to civilian, especially if they are

wounded. He emphasized the importance

of making the transition from Department

of Defense to VA health care as seamless as

possible. Dr. Reinhardt, Professor of

Economics and Public Affairs at Princeton

University, spoke of the VA health care system’s economic efficiency, stressing the

“moral imperative” of sharing with the 

private sector VA’s experience in providing

better care for less.

In his remarks, Arthur Hamerschlag,

VHA’s Chief of Staff, described VA’s

research priorities, including obesity, mental health, aging, end of life care, and the

needs of a new generation of veterans

returning from OEF and OIF. Hamerschlag

urged that VA research continue to address

the health care needs of these young men

and women who may struggle with comA Recap of the HSR&D National Meeting plex service-related health care needs for

many years to come.

Other meeting highlights included a talk

given by VA’s Chief Research and

Development Officer, Joel Kupersmith,

M.D. Dr. Kupersmith described VA’s longterm vision to provide optimal care for veterans with polytraumatic injuries such as

brain injury, burns, and spinal cord injury.

He also discussed the importance of linkin

genetic information to VA’s electronic 

medical record system. 

To learn more about research presented at

this year’s meeting, visit www.hsrd.research.

va.gov/about/national_meeting/2006. ■

Planning for the next HSR&D National

Meeting is underway. The theme will be

“Managing Recovery and Health Through

the Continuum of Care.” The Meeting is

tentatively scheduled for February 2007 in

Washington, DC. Watch the Web for

details at www.hsrd.research.va.gov 

Eugene Oddone, M.D., director of HSR&D’s Center for Health

Services Research in Primary Care in Durham, N.C., has received 

this year’s prestigious Under Secretary’s Award for Outstanding

Achievement in Health Services Research. Arthur Hamerschlag,

VHA’s Chief of Staff, presented the Award at the HSR&D National

Meeting.

The award recognizes Dr. Oddone’s innovation in health services

research and his examination of ways to improve the effectiveness

and delivery of primary care, reduce racial disparities in health care,

and foster self-management among veterans with chronic illness.

His work in identifying the underlying causes for racial disparities in access to and use of health

care was instrumental in establishing an important new VA research agenda. 

Dr. Oddone has served as director of the Center for Health Services Research in Primary Care

for the past eight years. Under his leadership, the number of investigators and amount of peerreviewed funding at the Center has increased significantly. 

Oddone Receives Under Secretary’s Award for Outstanding

Achievement in Health Services Research
gain the most benefit. Further, we must be

careful that quality monitoring and pay-forperformance metrics do not encourage clinicians to provide unwanted or unnecessary

screening tests. Work done by VA investigators, for example, has shown that such

measures do not accurately include patients

who refuse screening (in many cases,

appropriately, in view of age and comorbidities) after discussion with a provider.3

A Tailored Approach to Screening Needed

The argument for a more tailored approach

to recommending, implementing, and measuring screening is a strong one and most

clinicians intuitively (though perhaps not

quantitatively) incorporate clinical risk when

making decisions. Adequate implementation of this type of approach, however,

requires substantial further inquiry to better define population and individual risks

and benefits. Even with better quantification of individual benefit, a paradigm of

shared decision-making is necessary to

ensure that patients are making appropriate

and informed decisions. Research to help

better inform quantitative and qualitative

aspects of decision-making is a growing

area and merits more attention. 

Understanding when, in a given individual,

screening is worthwhile, and when it is either

harmful or an inefficient use of resources,

FORUM 

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

Martin P. Charns, D.B.A., Director, VA HSR&D

Center of Excellence, Boston, MA

Phil Crewson, Ph.D., Assistant Director, 

VA HSR&D, Central Office

Joseph Francis, M.D., M.P.H., Director, HSR&D

QUERI, Central Office

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

Center of Excellence, Ann Arbor, MI

Shirley Meehan, M.B.A., Ph.D., Acting Director,

VA HSR&D, Central Office

Michael J. Miller, M.D., Ph.D., Chief Medical

Officer, VA Network #1, Bedford, MA

Eugene Z. Oddone, M.D., M.H.Sc., Director, 

VA HSR&D Center of Excellence, Durham, NC

Clyde Parkis, Network Director, VISN 10,

Cincinnati OH

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

VA Central California Health Care System

The Journal of General Internal

Medicine recently published two special

supplements that focus on VA research.

The first, “Implementing Evidence into

Practice: Proceedings from the State of

the Art Conference,” presents the current

state of knowledge related to implementation research. The second examines

health and health care delivery issues

affecting women veterans, and highlights

VA organizational changes to improve

access to and quality of VA women’s

health care. Journal of General Internal

Medicine, March 2006; 21(2) & (3). 

is critical to improving our delivery of

screening services. ■

References

1 Agency for Healthcare Research and

Quality. U.S. Preventive Services Task

Force. Available at www.ahrq.gov/clinic/ 

uspstfix.htm

2 Hayward RA, Kent DM, Vijan S, Hofer

TP. Reporting Clinical Trial Results To

Inform Clinical Practice: The Need To Assess

Benefits and Harms For Lower Versus

Higher Risk Patients. Health Affairs 2005;

24(6):1571-81.

3 Walter LC, Davidowitz NP, Heineken PA,

Covinsky KE. Pitfalls of Converting Practice

Guidelines Into Quality Measures: Lessons

Learned From a VA Performance Measure.

Journal of the American Medical Association

2004; 291:2466-70.

Vijan continued from page 3