VA Health Care: Efforts to Prioritize and Translate Research into Clinical Practice

In addition to providing health care services, VA funds research on veterans' health conditions, including chronic conditions (such as diabetes) as well as illnesses and injuries resulting from military service (such as TBI). VA's ORD manages the agency's research program, including its intramural research. In fiscal year 2018, VA resources for its intramural research program included an appropriation of $722 million.

GAO was asked to review aspects of VA's research program. In this report, which focuses on VA's intramural research, GAO describes 1) how VA sets priorities for funding research, 2) VA efforts to facilitate translation of research into clinical practice, and 3) coordination between VA's research program and other VA entities.

To perform this work, GAO reviewed VA policies, reports, and other documents about VA research efforts. GAO also interviewed officials from ORD, three VA national clinical program offices, and two VA offices that focus on implementing evidence-based practices. In addition, GAO conducted site visits with four VA medical centers. GAO selected those locations because they house VA-funded research centers that focus on a range of topics and ORD programs that focus on disseminating and translating research. At each location, GAO interviewed medical center officials and VA researchers. GAO also reviewed VA summary data on research projects and funding for fiscal year 2018.

VA provided technical comments on a draft of this report, which GAO incorporated as appropriate.

The Department of Veterans Affairs (VA) uses stakeholder input and other information to set priorities for funding research projects. VA's Office of Research and Development (ORD) manages VA's intramural research program—that is, research funded by and conducted within VA, by VA researchers. To set priorities, ORD considers input from VA and non-VA stakeholders (such as agency leaders and a federal research advisory council, respectively) and data on veterans' health conditions. ORD encourages VA researchers to study—and collaborate with other VA researchers on—priority topics, such as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI).

ORD's Quality Enhancement Research Initiative (QUERI) and other VA entities facilitate translating research findings into clinical practice to improve care for veterans. QUERI is VA's central point of focus for research translation and provides a link between ORD, VA program offices, and providers. For example, one QUERI program is studying delivery of an evidence-based treatment for PTSD using telemedicine, specifically, by providing psychotherapy via video to veterans in rural areas. Another program recently adopted a new research translation strategy by establishing a requirement that research proposals for large, multi-center clinical trials include an implementation plan. VA officials said the goal of the new requirement is to encourage researchers to think about research translation from the beginning of a study—and how their work might be translated into practice.

VA officials from both ORD and the national program offices GAO spoke with described a variety of efforts coordinating on research. Such coordination can help inform research priorities and help program offices incorporate evidence-based practices in developing and rolling out national policies. For example, ORD officials said that VA researchers were serving as subject matter experts to the national program office developing a protocol and clinical guidelines for a new treatment for certain veterans with depression that is resistant to existing treatments.

In addition to providing care to more than 9 million veterans through the  nation’s largest integrated health care system, the Department of  Veterans Affairs’ (VA) Veterans Health Administration (VHA) funds  research focused on health conditions veterans may experience.  According to VA, the department’s research program has led to health  care breakthroughs that have improved the lives of veterans and the  public for more than 90 years. The department’s research has been  instrumental in medical advances such as therapies for tuberculosis  following World War II, the implantable cardiac pacemaker, the first  successful liver transplants, and the first powered ankle-foot prosthesis.

VA funds studies on a variety of topics through its intramural research  program—research that is funded by and conducted within VA by VA  investigators. This research has included genomic and tissue studies  done in laboratories; studies of suicide prevention efforts; and studies of  rehabilitation engineering, prosthetics, and orthotics. In general, these  studies can address veterans’ everyday health care needs as well as the  particular needs of veterans with illnesses and injuries resulting from their  military service.

VHA’s Office of Research and Development (ORD) manages VA’s  intramural research program. In fiscal year 2018, VA’s intramural  research program received an appropriation of $722 million. VA also  participates in extramural research, which is funded through other federal  and non-federal sources.

To support its mission of advancing health care for veterans and the  nation, ORD policy states that its research program should focus on  supporting research to increase the evidence base for treatments and  disseminating research results to put those results to use. The process of  “translating” research findings into clinical practice—also known as  “implementation”—can occur in many ways within VA. For example,  research translation can result in changes to direct patient care (e.g.,  introducing a new diagnostic tool or directing providers to follow a new  treatment protocol), or it can involve broader changes to VA programs  (e.g., implementing a new staffing policy for a particular provider type).  ORD works with other entities within the agency—including those that set  clinical policies—in research translation. Research translation is widely  accepted to be a long process; for example, one study reported that on  average, it takes 17 years for research evidence to reach clinical  practice. Numerous factors, such as limited resources and time for  providers to implement evidence-based practices in delivering clinical  care, can prolong the process of research translation.

Congress and others have previously raised questions about the extent to  which VA’s research program is fulfilling its intended purpose in  conducting research focused on veterans’ needs. You asked us to  review several aspects of VA’s research program. This report focuses on  VA’s intramural research program and describes   (1)  how VA sets priorities for funding research projects;   (2)  VA efforts to facilitate translation of research findings into clinical  (3)  coordination between VA’s research program and other relevant  parts of the agency on setting research priorities and translating  research into clinical practice.

For all three objectives, we reviewed relevant statutes as well as VA  policies, reports, and other documents about agency research efforts. We  reviewed, for example, VA directives that govern the intramural research  program and VA’s budget submission for fiscal year 2020. We also  interviewed ORD officials, including the Chief Research and Development  Officer and the directors of ORD’s four research services—offices within  ORD responsible for administering and supporting different types of  research efforts. In addition, we conducted site visits with four VA medical  centers that house ORD-funded research centers and other ORD  programs. We selected those sites based on their research centers’ and  programs’ areas of focus. Specifically, we selected sites with research  centers that focus on different clinical and research areas and with other  ORD programs that focus on disseminating research and translating  research into clinical practice. (See appendix I for these research centers  and programs.) At each site, we interviewed VA medical center officials  and researchers about VA’s research efforts and their local VA-funded  research projects. The information obtained during those site visits is not  generalizable. For context, we also reviewed VA data on research  projects and funding for fiscal year 2018.

To describe how VA sets priorities for funding research projects, we  reviewed documents such as VA requests for applications, which  describe the types of projects for which VA researchers may apply for  funding. We also interviewed ORD officials about how they set research  priorities, their current priorities, and how they incorporated those  priorities into their processes for funding research projects.

To describe VA efforts to facilitate translation of research findings into  clinical practice, we interviewed ORD and other VA officials who focus on  implementing evidence-based practices in VA. This included officials from  ORD’s Quality Enhancement Research Initiative (QUERI) program, which  works to translate research findings and evidence-based treatments into  clinical practice, as well as VA’s Diffusion of Excellence Office and  Evidence-Based Practice Program Office. We also reviewed VA  documentation of agency efforts to translate research findings,  documentation of VA research projects that led to changes in clinical  practice, and other documents related to research translation, such as  publications in academic journals. We focused our review on research  translation efforts pertaining to ORD’s intramural research program.

To describe coordination between VA’s research program and other  relevant parts of the agency on setting research priorities and translating  research into clinical practice, we interviewed officials from three VA  national program offices—the Office of Mental Health and Suicide  Prevention, Office of Rehabilitation and Prosthetics Services, and Office of Spinal Cord Injuries and Disorders System of Care—about their related  efforts. We selected these offices because the clinical areas in their  purview are relevant to VA research centers and programs we visited and  to VA’s research priorities at the time of our review. The information  obtained from those program offices is not generalizable to the efforts of  other program offices. We also reviewed documentation of research  efforts in which VA research program and national program office staff  had collaborated.

We conducted this performance audit from October 2018 to January 2020  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

VA, through VHA, operates the nation’s largest integrated health care  system. At the local level, VA has 172 VA medical centers that are  organized into 18 Veterans Integrated Service Networks (VISN). At the  national level, VHA’s central office includes approximately 75 national  program offices as of October 2019, which perform a range of clinical or  administrative functions. For example, some program offices are  responsible for specific clinical areas, such as spinal cord injury or mental  health care, and may develop policy for those areas.

To support VA’s health care delivery system, VA’s intramural research  program aims to improve veterans’ health by funding research on issues  that affect veterans, developing effective treatments for veterans, and  recruiting and retaining VA researchers. VA’s medical and prosthetic  research appropriation—$722 million in fiscal year 2018—funds VA’s  intramural research program. VA also uses funding from its other  appropriation accounts—$544 million in fiscal year 2018—to support VA’s  intramural research by paying some costs associated with this research,  such as equipment maintenance. According to VA, more than 60 percent  of VA researchers are also clinicians who provide direct patient care,  which helps translate VA research into clinical practice.

ORD manages VA’s intramural research program. Within ORD, there are  four research and development services that are responsible for  administering and supporting research; each research service has a  specific focus, such as biomedical research and rehabilitation research.  Each of the four research services is led by a director and has scientific  program managers who are responsible for specific research portfolios  (or topic areas) within their service. In addition to the four research  services, ORD has a Cooperative Studies Program that is responsible for  large-scale clinical trials and epidemiological studies within VA. (See  Table 1.) All five of these ORD components support research by funding  VA research projects. See appendix II for details on research funding  and awards. Organizationally, ORD falls within the Office of Discovery,  Education and Affiliates Networks, which was created in November 2018  to foster collaboration in addressing veterans’ health concerns.

ORD funds VA intramural research in a number of ways, such as the  following:

Merit Review Program. This program supports VA research projects  that are typically led by one VA researcher at one VA facility. ORD’s  four research services administer this program and are responsible for  soliciting, reviewing, selecting, and funding research proposals  submitted by VA researchers. Researchers may submit proposals  either in response to a request for applications on a specific topic  (sometimes called targeted or focused requests) or to a general  request for applications, for which researchers can propose projects  on a wider range on topics. To be considered for funding, research  proposals must be veteran-centric and meet other requirements.  Each ORD research service typically evaluates Merit Review Program  research proposals in two review cycles per year. Selected projects  are funded for a set number of years and have a maximum budget— typically for four years with a maximum amount of $1.2 million. The  Merit Review Program accounts for the majority of VA-funded  research studies that ORD funds.

Cooperative Studies Program. This program funds larger-scale,  multi-site clinical trials and epidemiological research studies on  diseases that affect veterans. VA researchers can submit proposals  at any time during the year. ORD’s Chief Research and Development  Officer and Cooperative Studies Program leadership evaluate  proposals in two review cycles per year. The time frame and budget  for selected studies varies, depending on features of specific studies.

Career Development Program awards. The research services’  Career Development Program provides funding to support, train and  mentor individuals early in their career as VA researchers, which can  include funding for specific research projects.

Funding to support VA research centers and entities. In addition  to funding individual research projects and researchers, ORD funds  research centers and entities that focus on specific research areas.  For example, the rehabilitation research service provides “core  funding” to support 12 research centers focusing on areas such as  limb loss, spinal cord injury, vision loss, and auditory disorders. This  type of funding is competitive, and VA researchers must recompete in  5-year cycles.

Once research has been completed, the findings can inform additional  research. For example, research findings from a study on tissue could be  used to inform a study done on humans in a controlled clinical setting,  such as a clinical trial, which could in turn inform research that tests the  effectiveness of a particular intervention in a less-controlled community  setting. This concept is referred to as the “research pipeline.” Research  findings leading to broad changes in clinical practice that affect public  health is considered the end of the pipeline.

Within VA, research findings can be translated into clinical practice in a  number of ways, such as by implementing a new diagnostic tool,  changing the treatment protocol for a particular disease, adding a new  prompt for providers in the electronic health record, or developing a new  clinical policy or a clinical practice guideline. The specific outcome might  vary depending on the study or type of research. For example, one body  of VA research has confirmed the utility of an intimate partner violence  screening tool for female veterans in primary care settings. These  findings will be used in developing national guidelines for screening for,  and responding to, intimate partner violence. In addition, VA research  contributed to the development of a clinical practice guideline for the  management of upper extremity amputation rehabilitation. This guideline  is a tool to assist clinicians and health care professionals with their  decision-making when caring for individuals with upper extremity  amputation.

VA Uses Stakeholder Input and Other Factors to Set Priorities for Funding Research Projects

ORD leadership sets VA’s national research priorities based on input from  internal and external stakeholders and other factors. The directors of  ORD’s four research services, in turn, set their own service-level research  priorities based on the national priorities, veterans’ specific needs, and  other considerations. Once these research priorities are set, ORD officials  use a range of approaches to incorporate them when funding research,  such as by funding collaborative research efforts focused on specific  priorities. ORD officials said in funding research, they also consider other  clinical and research needs that are not identified as priorities but are still  important to veterans’ health, such as encouraging researchers to test  new ideas.

VA’s ORD Sets National Research Priorities Based on External and Internal Input

At the national level, ORD leadership sets VA’s overall research priorities  based on input from internal and external stakeholders and other factors.  ORD sets these priorities annually, and its priority-setting process  involves discussions with stakeholders and reviews of relevant VA data,  according to ORD officials. For example, ORD sets priorities using the  following methods:  Input from internal VA stakeholders. The directors of ORD’s  research services provide input to the Chief Research and  Development Officer on issues they see as priorities. Officials outside  of ORD, such as the leadership of VA’s new Office of Discovery,  Education, and Affiliated Networks, of which ORD is a part, and other  VA leaders also provide input, according to ORD officials.

Input from external stakeholders. ORD officials said they also  consider input from the National Research Advisory Council, a 12- member federal advisory committee that provides advice to VA on its  research and development efforts, such as recommending which  topics to include among the agency’s research priorities. According  to ORD officials, the office also obtains input on research priorities by  meeting with veterans service organizations and by hearing from  veterans through veterans’ engagement opportunities. In addition,  Congress provides direction and input on topics that VA should study,  such as through legislation or committee reports.

Other factors. ORD officials said, for example, they set research  priorities using VHA data on the prevalence of health conditions  among veterans and Veterans Benefits Administration data on military  deployment-related conditions.

Based on stakeholder input and other factors, ORD established three  types of national research priorities: strategic, cross-cutting clinical, and  other priorities. (Figure 1 shows these research priorities for fiscal years  2019 and 2020.) As of October 2019, ORD officials told us they were  determining what these priorities will be for fiscal year 2021.

Strategic priorities are broad long-term priorities that focus on VA’s  research capability, resources, and operations, rather than on specific  clinical conditions, according to ORD officials. For example, one of  VA’s strategic priorities is to “put VA data to work for veterans.” As  part of this priority, VA aims to improve its ability to leverage the  agency’s medical data to improve veterans’ care. ORD officials said  they plan to revisit these priorities about every 5 years, though the  specific initiatives that fall within each priority can change annually. As  an example of how the initiatives within the strategic priorities can  change, ORD officials said that given VA’s plans to implement a new  electronic health records system, the National Research Advisory  Council advised ORD in 2019 to focus on mitigating any unintended  consequences of this transition on research, as part of the strategic  priority on data. ORD officials said that as a result of this input, they  are increasing the intensity and scope of their efforts pertaining to this  transition.

Cross-cutting clinical priorities, in contrast, focus on predominant  clinical conditions seen in veterans and can change yearly, according  to ORD officials. For example, one current cross-cutting clinical  priority is PTSD. As part of this priority, VA supports research to better  understand the underlying biology of PTSD, refine approaches for  diagnosing this condition, and develop and test new treatments. ORD  officials said they plan to add precision oncology as a new cross- cutting clinical research priority for fiscal year 2021, based on input  from VA leadership. ORD officials also said they plan to broaden the  Gulf War illness cross-cutting clinical priority to include the effects of  military service-related toxic exposures, more generally. This planned  change is based in part on veterans service organization and Gulf  War veteran input.

Other priorities are those that VA will focus on in the near term,  based primarily on input from Congress, veterans service  organizations, and other non-ORD stakeholders, according to ORD  officials. For example, several of these priorities for fiscal year 2020— such as addressing the prosthetic needs of women veterans and  exploring ways to use an “exoskeleton” for veterans who have  experienced strokes or traumatic brain injury (TBI)—were identified by  Congress as research needs.

ORD’s Four Research Services Set Their Own Priorities Based on National Priorities and Veterans’ Specific Needs and Conditions

In addition to national priorities for research funding, ORD permits its four  research services to set their own service-level research priorities, which  are based in part on the national priorities. According to ORD officials, the  directors of the four ORD research services—the biomedical laboratory,  clinical science, health services, and rehabilitation research and  development services—have latitude to set their own priorities, given their  expertise in, and the particular focus of, their respective research areas.  These directors told us they may consider a range of internal and external  factors when setting priorities, including: Internal factors. The four research service directors told us they take  into account VA’s national research priorities when determining their  priorities. For example, the director of the biomedical laboratory  service identified VA’s five cross-cutting clinical research priorities as  priorities for this research service. Also helping shape research  priorities are VA stakeholders, such as the Secretary of VA and  scientific program managers—the ORD staff who are responsible for  specific topic areas within their services. In addition, service directors  told us they use VA data on veterans’ health conditions when setting  research priorities. The leadership of ORD’s rehabilitation research  service, for example, told us they review VA data on the top service- connected conditions for which veterans are receiving disability  benefits, and take that factor into consideration, along with less  prevalent conditions such as spinal cord injuries, that also have a  significant impact on veterans’ function and independence when  setting priorities. (See text box for examples of research projects on  spinal cord injury, which is one of the rehabilitation research service’s  priorities.)

Exoskeleton-assisted walking   Exoskeletons are motorized prostheses  that are worn outside a person’s clothes  and provide powered hip and knee  motion, to help veterans with spinal cord  injuries stand and walk. In this  photograph, a research participant with a  spinal cord injury uses an exoskeleton at  the Bronx VA medical center.

Department of Veterans Affairs (VA) Research on Spinal Cord Injuries   VA provides care for about 27,000 veterans with spinal cord injuries. Veterans with  spinal cord injuries may have secondary bone loss, muscle atrophy, and other  conditions. They also have an increased prevalence of diabetes, heart disease, stroke,  bowel and bladder incontinence, chronic pain, and reduced quality of life, according to  VA.  VA’s National Center for the Medical Consequences of Spinal Cord Injury, located at  the Bronx VA medical center, is one of the VA’s rehabilitation research service’s  research centers. The Center’s mission is to improve quality of life and increase  longevity in individuals with spinal cord injuries by identifying and intervening to reduce  and prevent the secondary consequences of spinal cord injuries. Examples of the  Center’s VA-funded research include:  Studying the safety and efficacy of exoskeleton-assisted walking in rehabilitation  settings and in home and community environments,

Developing and testing innovative approaches to improve bowel function,  Studying the impact of low blood pressure and developing approaches to help  individuals maintain normal blood pressure,  Studying individuals’ difficulties regulating their body temperature, and developing  interventions to address this problem, and

Using magnetic and electrical stimulation to enhance arm and leg function.

External factors. Congress can play a role in shaping the research  services’ priorities. For example, the health services research service  has identified research on policies and programs included in recently  enacted legislation, including the VA MISSION Act of 2018 and the  Comprehensive Addiction and Recovery Act of 2016, as a priority.  Input from other federal partners, such as the National Institutes of  Health (NIH) or the Department of Defense (DOD), also can influence  the priorities of ORD’s research services. Officials with the  rehabilitation research service, for example, said they meet with DOD  officials about research efforts and that input from DOD on the health  issues seen among active-duty service members can help them  anticipate what health issues those service members might face when  they transition to veteran status. They can then use that information  when deciding which clinical areas to prioritize. In addition, one  director said that input from veterans service organizations can shape  research priorities, while another director obtains input from veterans  through a VA veteran engagement group that provides information on  the needs of veterans.

ORD’s service-level research priorities cover a wide range of areas, such  as service-connected conditions and conditions that veterans may  experience as they age. As of October 2019, the services had each  identified between 10 and 20 research priorities. (See the box below for  examples.)

Examples of Office of Research and Development’s Service-Level Research Priorities, as of October 2019   Traumatic brain injury (TBI) is a research priority for all the  services. For example, the effect of prolonged opioid use on  TBI outcomes is a priority for the rehabilitation research  service.  Post-traumatic stress disorder (PTSD) is a research  priority for several services. For example, PTSD and the  conditions that commonly co-occur with this condition is a  priority for the clinical science research service.  Pain is a research priority for all the services. For example,  pain mechanisms and treatments, including alternatives to  opioids, is a priority for the clinical science research service.

Spinal cord injuries are a research priority for some services.  For example, disability—including spinal cord injury and TBI— is a priority for the health services research service.  Suicide prevention is a research priority for multiple services.  The biomedical laboratory service, for example, has an  emphasis on biological markers of suicide.

Aging-related issues are a research priority for several  services. For example, “long-term care, aging, and caregiver  support” is a priority for the health services research service.

ORD Uses a Range of Approaches to Incorporate Priorities When Funding VA Research

Once priorities are set, ORD officials told us they use a range of  approaches to incorporate those priorities when funding research  projects, such as: encouraging researchers to study priority topics,  considering priorities when deciding which projects to fund, and funding  collaborative research efforts that are focused on specific priorities. In  addition to the research priorities, ORD officials said they also consider  other clinical and research needs when funding VA research, such as  encouraging researchers to test new ideas in clinical areas that are not  identified as priorities but are still important to veterans’ health.

ORD officials’ approaches to incorporating priorities when funding  research included the following examples:

Encouraging researchers to study priority topics. ORD’s research  services highlight their research priorities in their requests for  research proposals. In some cases, they use targeted requests for  research proposals solely on priority topics. In fiscal year 2019, ORD  issued targeted requests for proposals linked to priorities such as  suicide prevention, TBI, and the VA MISSION Act. In other cases, the  research services highlight their research priorities in general requests  for applications, which permit VA researchers to submit proposals on  both priority and non-priority topics. For example, in 2019, the  rehabilitation research service issued a general request for research  proposals, stating that four research priorities—the prosthetic needs  of women veterans, exoskeleton research related to patients with  stroke and TBI, non-pharmacological interventions for chronic pain,  and the effects of prolonged opioid use on long-term outcomes from  TBI—were of particular interest for that funding cycle. (See text box  for examples of VA research projects on priority topics.)

Department of Veterans Affairs (VA) Research on Traumatic Brain Injury (TBI) and Stress Disorders  Traumatic brain injury (TBI), a common injury among veterans of conflicts in Iraq and Afghanistan, can lead to a number of physical,  cognitive, and emotional problems, such as memory and attention issues. These veterans may also experience post-traumatic stress  disorder (PTSD), which can lead to anger, irritability, depression, substance abuse, and other symptoms, according to VA.  VA’s Translational Research Center for TBI and Stress Disorders, located at the Jamaica Plain (Boston, Mass.) VA medical center, is  one of VA’s rehabilitation research service’s research centers. The Center seeks to better understand the complex cognitive and  emotional problems faced by these returning veterans, with the goal of developing better treatment options. The Center runs a  longitudinal cohort study that collects imaging, genetic, and other data on returning veterans. Examples of the Center’s VA-funded  research projects include:  A study to assess the efficacy of the STEP-Home program, a 12-week workshop to help veterans who have served in Iraq or  Afghanistan. The program aims to strengthen behavioral and emotional skills so that veterans are better equipped to rejoin their  families and civilian communities.  Studies to identify sub-types of PTSD, and to assess the long-term effects of PTSD and mild TBI.

Research on the use of non-invasive brain stimulation to help patients with PTSD.

Development of the Boston Assessment of Traumatic Brain Injury- Lifetime tool, a clinical interview to characterize head injuries  and diagnose TBI throughout a patient’s lifespan.

Considering priorities when deciding which projects to fund.  Directors from all of ORD’s four research services stated that the  scientific merit of research proposals—based on the proposals’  significance to veterans’ health, feasibility, and other criteria—is a key  factor in funding decisions. Several directors said they may decide  to fund a meritorious project that addresses one of their research  priorities in lieu of another project that was ranked similarly or higher  but does not address a priority. Some of the directors noted that this  only applies to a small share of funded projects, but is part of how  they align research projects with priorities.

Funding collaborative research efforts. The biomedical laboratory  service has funded field-based meetings to plan collaborative multi- site research programs to speed the development of treatments for  service-related illnesses and injuries. The director of this research  service said that in 2019, these research-planning meetings focused  on ORD’s national research priorities, such as TBI, PTSD, and pain  and opioids, among other topics. Also, starting in 2019, the health  services research service is providing funding for its research centers  to collaborate with other VA researchers on three of its priority areas:  suicide prevention, opioid reduction and pain, and access to care.  Officials from this research service said they also hold “State of the  Art” conferences that can help VA make progress on priority areas.  For instance, VA officials held a September 2019 conference on  managing pain and addiction, specifically focusing on strategies to  improve opioid safety. VA officials said this conference involved a  wide range of VA staff and resulted in recommendations about  research priorities, including areas where more research is needed.

In addition to the research priorities, ORD officials said they consider  other clinical and research needs when determining which health care  research efforts to fund. Rehabilitation research service officials  specifically noted that if they did not fund research in non-priority clinical  areas, it would hinder their goal of encouraging researchers to test new  ideas in other areas that are important to veterans’ health, which the  officials say can lead to discoveries. The importance of innovation was  echoed by other ORD officials, as well. Some ORD research service  directors said that while new research needs emerge over time—as  stakeholders highlight particular clinical needs, or VA leadership  changes—it is important for VA research efforts to anticipate veterans’  longer-term needs and focus on more enduring issues, too. Officials from  one research service said, for example, that they encourage researchers  to focus on issues that will still be important in several years, such as  women veterans’ care, because research can take years to yield results.

In addition, some ORD research service directors said that although  service-connected conditions are key parts of their research portfolios,  they also work to address other conditions. Clinical science service  officials said, for example, that they have a broad charge to support  research into any disease or condition that affects veterans’ health. One  of their priorities is researching diseases with a high health care burden  among veterans, which may or may not be related to veterans’ military  service. Rehabilitation service officials noted that their work focuses on  veterans’ disabilities and impairments incurred through military service  but is not limited to service-connected conditions. The officials said that  because VA provides lifetime care to veterans, their research portfolio  addresses events that cause impairment and disability throughout a  veteran’s lifespan, including the aging process. For example, their  research portfolio includes research on medical conditions that veterans  may experience as they age, such as stroke, and chronic conditions like  diabetes and kidney disease.

As part of their efforts to consider multiple clinical and research needs,  officials from the health services research service told us they are  analyzing their overall research portfolio to determine where more or less  research funding may be warranted. The officials explained that as part of  their strategic planning efforts, they are identifying any areas they have  “under-invested” in, and any areas that have received significant funding  in the past but might no longer need that degree of investment. Among  other things, they are considering the extent to which research on health  conditions is already being done by other research organizations, such as  NIH. They noted that while addressing chronic diseases is important to  VA and its veteran population, it is possible that research on certain  diseases is being covered by other research partners. In contrast, they  said, there are areas where VA may have a unique ability to contribute to  research because of its nationwide health care system or because it is  ahead of the curve in health care trends, such as in telehealth and in  integrating mental health care into primary care settings. Officials said  their portfolio analysis could result in some “resetting” of research  priorities and funding after the analysis is completed in 2020.

Looking forward, ORD officials shared examples of approaches they are  taking to boost the agency’s ability to address its research priorities. For  example, ORD officials said there are a limited number of VA researchers  working in certain priority areas, such as suicide prevention, which the  officials said can hinder their efforts to fund new research projects.  Among the efforts to boost the number of researchers working on priority  areas, officials from one research service said they recently began  incorporating their research priorities into the service’s Career  Development Program funding awards. In addition, in 2019, ORD  implemented a new method to spur and track ORD progress in  addressing priorities. According to ORD leadership, as part of this  method, ORD staff will identify the actions and resources needed to  address specific priorities, and meet quarterly with the Chief Research  and Development Officer to review their progress and identify next steps.

ORD’s QUERI Program and Other VA Entities Facilitate Translating Research into Clinical Practice

VA has a variety of efforts to facilitate translating research findings into  clinical practice to improve the care veterans receive. These efforts  include those undertaken by ORD’s QUERI program, its health services  research service, and VA’s Diffusion of Excellence Initiative, as discussed  below.

ORD’s QUERI provides a link between the research program, VA  program offices, and VA providers. According to the QUERI director,  QUERI serves as the center of VA’s efforts to translate research into  clinical practice. QUERI’s overall mission is to improve veteran health by  rapidly implementing research findings and interventions into clinical  practice. QUERI is housed within ORD, but funded separately by non- research dollars.

QUERI facilitates research implementation through activities such as the  National Network of QUERI programs. According to the director of  QUERI, these programs are partnered with VA national program offices,  and they take various practices—often identified or developed through VA  studies—and implement them at the regional or national level. For  example, through its “Bridging the Care Continuum” QUERI investigators  focus on improving the health of vulnerable veteran populations, such as  homeless veterans, by implementing a co-occurring mental health and  substance use treatment within multiple VA medical centers. (See text  box for an example of implementation through a QUERI National  Program.) In addition, QUERI funds resource centers with technical  experts who can help promote and review best practices for  implementation. Specifically, one resource center—the Center for  Evaluation and Implementation Resources in Ann Arbor, Mich.—is  available to VA researchers for consulting on strategies to translate  research.

Example of Quality Enhancement Research Initiative (QUERI) Research Translated into Clinical Practice: Telemedicine  Outreach for Post-Traumatic Stress Disorder (PTSD) in Small Rural Community-Based Outpatient Clinics  The goal of the Virtual Specialty Care QUERI National Program is to implement and evaluate promising clinical practices that  incorporate technologies to improve access to specialty care for veterans in rural settings. One example of its efforts is the  telemedicine program, based on VA-funded research demonstrating the effectiveness of using telemedicine outreach for veterans with  PTSD. The Office of Rural Health and the Virtual Specialty Care QUERI partnered to implement this telemedicine program which  provides evidence-based psychotherapy for veterans with PTSD via interactive video either from their homes or at community-based  outpatient clinics, and connects veterans with care managers to coordinate their treatment. According to VA, as of June 2019 the  telemedicine program is being implemented in six states and 1,073 “hard to reach” veterans have been engaged via the program.

In 2019, QUERI published the “Implementation Roadmap,” a new  resource—intended for a variety of users, including researchers,  clinicians, and leadership—to advance research translation at VA and  provide information on how to identify, implement, and sustain evidence- based practices to improve the quality of care for veterans. The Roadmap  outlines the different stages of research implementation, specifically  delineating when research is ready to be implemented into clinical  practice. The QUERI director told us staff created the Roadmap as a  teaching tool to provide guidance on how to implement research at VA  and when to collaborate with QUERI. In addition, the director of QUERI  told us the Roadmap demonstrates the cyclical nature of research and  how implementation is part of a continuous scientific process, not an “end  game.” QUERI officials said that throughout the process of  implementation, new research questions might be generated, which  QUERI can use to inform further investigation or follow up studies.

ORD’s health services research service funds studies that focus on  direct application of research in clinical practice. ORD’s health  services research service supports research translation by funding  studies focused on how interventions work in “real world” settings and on  implementing VA research findings into clinical practice. For example,  little is known about the quality of non-VA care for sex-specific services  such as mammography, according to VA, despite increasing numbers of  women veterans relying on such care due to limited availability within VA.  One study funded by this research service looked at strategies for  provision, coordination, and quality of oversight of non-VA care for  women, and assessed perceptions and experiences with non-VA care  among women veterans. Among other things, the study found VA sites  providing mammography were more likely to notify women more quickly  of abnormal results than non-VA sites, but non-VA sites were more likely  to meet guidelines for timely follow-up.

In addition to funding individual research studies through merit review, the  health services research service funds 18 Centers of Innovation (COIN),  each of which focus on one or more areas of research that address  questions significant to clinical and operational partners. For example,  officials from the dual-site COIN in Seattle and Denver, which focuses on  veteran-centered and value-driven care, told us they are participating in a  study co-funded by VA, NIH, and DOD evaluating non-pharmacological  options to treat pain and co-occurring mental health conditions in  veterans with chronic pain; the study will be overseen by VA’s Office of  Patient-Centered Care and Cultural Transformation. According to the  research service officials, the COINs are designed to bring researchers  from multi-disciplinary research teams together to engage in research and  establish partnerships that can affect VA policies, practices, and health  care outcomes. (See text box for an example of research funded by the  health services research service that has been translated into clinical  practice.)

Example of Research Translated into Clinical Practice across VA: Reducing Catheter-Associated Urinary Tract Infections  The Center for Innovation (COIN) in Ann Arbor, Mich., partners with VA clinical, policy, and operations leaders to implement and  evaluate ways to make health care safer, more effective, and affordable for veterans. For example, an investigator from this COIN,  funded in part through a Career Development Award, conducted research on enhancing patient safety by reducing catheter-related  infections. Then, in partnership with another VA researcher, this investigator conducted a study funded by the health services  research service and created a “bundle” of activities to implement in VA hospitals throughout Michigan. This included removing  catheters as soon as possible and increasing the use of recommended infection control practices. VA researchers assisted the  National Center for Patient Safety in implementing the practices, and the success of the “bundle” resulted in its national  implementation in more than 1,000 hospitals. VA reported that catheter-associated urinary tract infection rates decreased by 32  percent in participating general medical and surgical units.

According to officials from the health services research service, in  addition to funding studies and COINs, the service maintains four  resource centers, which provide support to VA researchers in several  areas, including data, health economics, and dissemination. For  example, the Center for Information Dissemination and Education  Resources circulates research findings through VA newsletters,  cyberseminars, and publications and educates clinicians and researchers  on sharing findings. In addition, the center coordinates meetings and  conferences—such as the service’s joint national conference with  QUERI—which provides an opportunity for VA researchers to present  scientific findings and discuss the implementation of findings into practice.  In 2017, the conference focused on accelerating the adoption and spread  of practices and improving VA’s ability to utilize healthcare data to  enhance care for veterans.

Officials from the health services research service told us that, starting in  2019, they began implementing two new strategies to increase the impact  of VA research on veterans’ health care. First, the service began a new  effort to bring together and fund consortiums of researchers from multiple  COINs each with a particular focus on implementing evidence-based  practices in a given priority area. VA officials told us that as of October  2019, the health services research service established two consortiums of  researchers to focus on suicide prevention and opioids and pain  management. The service is planning to add two additional consortiums  in 2020 to focus on access to care and telehealth and connected care.

Second, in 2019 the research service provided additional funding  opportunities for COINs to submit research proposals that include five- year goals for the impact of their research, such as VA policy changes or  spreading the research to additional sites, and yearly milestones for  achieving those goals. Per the request for applications, applicants’  proposals must provide information on how the COINs plan to apply  health services research methods, including implementation research.  According to VA, as of October 2019, 20 proposals had been selected to  receive funding through this new strategy.

Diffusion of Excellence Initiative aims to encourage practitioner  implementation of research-based practices outside of ORD. VA’s  Diffusion of Excellence Initiative, created in 2015, established an annual  competition—known as VA’s “Shark Tank”—to engage employees in  implementing innovative practices that will positively impact veterans.  According to officials from the Diffusion of Excellence Initiative, many of  these practices are based on evidence-based research. Under the  competition, “investors” (directors from VA medical centers and VISNs)  make offers on practices that have been successfully implemented in at  least one VA medical center, and the winning investor receives facilitated  implementation support so that the practice can be implemented at the  investor’s medical center. The officials told us that several of these  practices have been identified as exemplary practices and are now being  used nationally across multiple VA health care settings. For example,  they described one such practice, a tooth-brushing routine implemented  for hospitalized veterans to decrease the risk of oral bacteria getting into  the veterans’ lungs, which research had shown could increase their risk of  pneumonia. According to officials from the Diffusion of Excellence  Initiative, the practice decreased hospital-acquired pneumonia by 90  percent at the pilot site, and is being implemented in other VA health care  settings.

Other VA efforts to facilitate research translation into clinical  practice. In addition to the changes to the existing efforts for facilitating  research translation, VA has recently taken other actions to help ensure  findings from VA research are integrated into practice. In response to  ORD’s current strategic priority to “increase the substantial real-world  impact of VA research,” the director of ORD established a workgroup to  create “The Research Lifecycle,” which was published in October 2019.  The lifecycle is a resource that specifies processes to help move research  to direct application in routine clinical care. It describes the research and  implementation process from identifying innovations that align with clinical  priorities to ensuring practices are sustained in clinical care, beyond  research and implementation. For example, one phase of the process  involves evaluating interventions to determine if they are ready to be  implemented into clinical practice. The director of QUERI told us that the  information in the publication is broadly applicable across all ORD  research and that like the QUERI Implementation Roadmap, the  publication reiterates that research is a continuous process rather than a  straight line with an endpoint. In addition to the research lifecycle, an  official from the agency’s Cooperative Studies Program—which funds  large, multi-center clinical trials—told us the program established a new  requirement in 2019 that research proposals include an implementation  plan. The goal of this change is to encourage researchers to think about  research translation from the beginning—and how their work might be  translated into clinical practice, according to the program official.  Researchers planning to conduct these types of clinical trials will have the  opportunity to consult with internal implementation experts to develop  plans to translate the research into clinical practice, according to ORD  officials.

VA Officials Described Efforts to Coordinate on VA Research Priority Setting and Translation

VA officials from both ORD and the national program offices we spoke  with described their experiences coordinating on research. Coordination  can help both to inform research priorities to make them most useful and  applicable, and to encourage the translation of research into clinical  practice, which can help VA meet its broader goal of ensuring its research  is benefiting veterans’ health.

National program offices—such as those for clinical specialties including  mental health or spinal cord injury care—provide input to ORD both on  research priorities and on efforts to translate research findings into clinical  practice within their respective issue areas. For example, officials from  the Office of Mental Health and Suicide Prevention told us that their lead  staff for suicide prevention participated in strategic planning efforts with  ORD to determine a “road map” for current and future research in this  area. This VA program office official described working with ORD to  provide clinical perspective on gaps in research and clinical care related  to suicide prevention, among other things. Given the disproportionately  higher rate of suicide among veterans compared with the civilian  population, such coordination can help maximize VA’s efforts both in  research and in clinical care. Among other things, the road map identifies  remaining questions related to suicide prevention to be addressed by VA  and other researchers, categorized by type of research (e.g.,  epidemiological or intervention).

Coordination between the research program and national program offices  also can facilitate the conduct of the research itself, encouraging research  that is viable and relevant to be conducted and translated into practice.  For example, ORD leadership told us that program office buy-in on VA  research priorities and efforts can lead to VA clinicians being more willing  and able to participate in VA research. ORD leadership also told us that  ORD has recently begun requesting that researchers engage and  collaborate with relevant program offices during the planning process for  large multi-site clinical trials, including seeking input from program offices  on research proposals. Potential questions for researchers to ask include:  does the relevant program office think the proposal’s topic is clinically  important; is the research proposal feasible; and will it answer a question  that is important from a clinical perspective? According to ORD officials,  because VA funds a small number of these types of trials—which are  intended to provide a definitive answer to a clinical question—researchers  want to be sure the studies are relevant to the needs of the program  offices.

One specific example both ORD and program office officials provided was  related to their coordination on research on osseointegration—a medical  procedure through which a metal rod is inserted into the bone at the site  of an amputation, allowing a prosthetic limb to be attached through the  skin directly to the remaining bone of the amputated limb. Officials from  the rehabilitation research service told us that they have been working  with program office officials to consider aspects of implementation prior to  beginning a clinical trial, including the availability of the surgical procedure  throughout VA and the types of post-operative care patients would need.  These officials told us that their goal is to ensure the clinical trial is  designed for translation.

In addition, because national program offices establish policies that affect  the provision of care across VA, program office officials told us that  collaboration with ORD can help them to incorporate evidence-based  practices in developing and rolling out these policies. For example, an  official from the Spinal Cord Injury and Disorders System of Care program  office told us that it incorporated research findings when it revised its  national policy—including a new requirement for all spinal cord injury  centers to have vocational rehabilitation counselors on staff. A program  office official told us that the addition of this requirement resulted from VA  research—led by a researcher clinician—that found that veterans with  spinal cord injuries who received specialized vocational support services  had the best chance of success for job placement and continued  employment. In another example, ORD officials told us that VA  researchers were serving as subject matter experts to the national  program office developing the protocol and clinical guidelines for  implementing intranasal ketamine as a new treatment for certain veterans  with treatment-resistant depression.

ORD and program office officials described using both informal and  formal approaches to coordinate on research priorities and translation.  For example, program office officials told us about occasional  participation of ORD staff in their regular meetings and calls, as well as  relationships between program office staff and individual researchers.  ORD officials from one service told us that their scientific portfolio  managers serve as a sort of liaison between researchers and clinical  program office partners. These officials told us that because VA’s  research program is intramural, there is an ongoing discussion with  researchers and others within VA in setting research priorities.

Although VA officials were mostly positive in describing coordination  between the research program and program offices, some officials noted  opportunities for improvement, as well. Specifically, officials from the  three national program offices we spoke with said it would be beneficial to  have a more formal or systematic approach for coordination with ORD.  An official from one national program office said a more systematic  process would be helpful, so that collaboration is not so dependent on  individual relationships or personalities. Officials from another national  program office noted that they considered having one staff person as a  dedicated resource to liaise with ORD, but lacked resources to do so.

Given limited time and competing priorities for researchers and program  office officials, ORD officials told us that it would be best to focus on  strategic coordination, and noted that some such efforts are underway.  Specifically, ORD leadership acknowledged that it would be helpful for  ORD and program offices to engage more in general—particularly related  to ORD’s research priorities. However, because ORD leadership said it  would not be efficient to have to go “door to door” to each individual  program office or VISN to have those discussions, it would be more  helpful to find more strategic ways to engage. For example, ORD  leadership said that ORD’s inclusion in larger annual VHA strategic planning sessions could be a way to facilitate strategic coordination.  Similarly, health services research service officials told us that service’s  new effort to build consortiums of researchers focused together on a  particular priority area may also facilitate coordination between  researchers and clinical program offices, particularly on key topics for VA,  such as suicide prevention and opioids. In addition, ORD leadership told  us that ORD is focusing its efforts on “big ticket items”—such as larger  studies or clinical trials through the Cooperative Studies Program—where  there can be a big impact through collaboration with program offices,  because a single study generally does not lead to changes in clinical  practice.

Another mechanism available to facilitate strategic coordination between  the research program and national program offices is ORD’s QUERI— particularly its Partnered Evaluation Initiatives—through which  researchers partner with national program offices to evaluate specific  initiatives with potentially high impact on VA national policy. For  example, QUERI investigators have partnered with the Office of Mental  Health and Suicide Prevention to evaluate an upcoming initiative to send  “caring letters” to veterans who have called the Veterans’ Crisis Line and  have been engaged in VA care recently. Caring letters, letters noting that  the veteran is cared about and matters, are an intervention shown to be  effective in reducing suicides in various at-risk populations. In addition,  VA program office officials told us that while most VA program offices  have their own internal program evaluation services, they do not have  sufficient resources to evaluate the effectiveness of all of their programs  and policies, motivating them instead to work with QUERI and ORD. For  example, the Office of Mental Health and Suicide Prevention has also  partnered with QUERI on the STAR VA program, to examine non- pharmacological approaches to treating agitation and other issues in  veterans with dementia. Program office officials told us that they can use  the results of these evaluations to influence policy, standard operating  procedures, and treatment in the field.

In summary, VA is uniquely positioned to implement research into clinical  practice because of the research program’s adjacency to such a large,  integrated health care system. As we have noted, coordination between  the research program and partner entities could help ensure VA-funded  research results in the spread and adoption of evidence-based practices.  VA recognizes the importance of this coordination and continues to  actively pursue effective coordination strategies.

We provided a draft of this report to VA for review and comment. VA  provided technical comments, which we incorporated as appropriate.

We are sending copies of this report to the Secretary of the Department  of Veterans Affairs and other interested parties. In addition, the report is  available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or farbj@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix III.

Appendix I: Department of Veterans Affairs (VA) Locations Selected for Site Visits

Appendix II: Information on Department of Veterans Affairs’ (VA) Intramural Research Program Funding Levels for Awards

In fiscal year 2018, VA’s appropriation for its intramural research program  totaled $722 million. Of this amount, $558 million was for awards made by  the Office of Research and Development’s (ORD) four research services  and the Cooperative Studies Program. Table 3 below presents data on  VA’s intramural research program funding and awards for fiscal year  2018.

Appendix III: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Raymond Sendejas (Assistant  Director), Julie T. Stewart (Analyst-in-Charge), Lauren Anderson, Jennie  F. Apter, Robin Burke, and Taylor German made key contributions to this  report. Also contributing were Jacquelyn Hamilton and Vikki Porter.

VA provides health care to over 9 million veterans each year. It also funds research on veterans’ health conditions—including chronic conditions, like diabetes, and illnesses and injuries resulting from military service, like traumatic brain injury.

We reviewed, among other things, how VA works to help translate research findings into clinical practice to improve care. For example, VA researchers are studying the delivery of psychotherapy for PTSD via video to veterans in rural areas. VA is also studying the use of exoskeletons to help veterans with spinal cord injury.