Amputation Research Is Focus Of VA 'QUERI' Meeting

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Amputation Research Is Focus Of VA 'QUERI' Meeting
By Dr. Mindy Aisen
U.S. Medicine
July, 2004

VA's Office of Research and Development recently held a "Traumatic Amputation QUERI (Quality Enhancement Research Initiative) Workshop" in Washington, D.C., to teach VA rehabilitation investigators the QUERI process-a method for systematically integrating research findings and evidence-based recommendations into routine clinical practice. The meeting was also aimed at encouraging established QUERI investigators in VA to pursue studies on amputation and prosthetics.

The event was precipitated in part by the influx of traumatic-injury amputees from Iraq and Afghanistan into Walter Reed Army Medical Center (WRAMC) in Washington, D.C., and the anticipated influx of these amputees into the VA health care system. Due to advances in body armor and battlefield first aid, many soldiers who would otherwise have been killed in action are surviving, albeit with severe injury to their extremities. To date, more than 200 troops have returned from Iraq and Afghanistan as major-limb amputees, with one in five having lost more than one limb.

What Is 'QUERI'?
QUERI, initiated by VA's Health Services Research and Development Service in 1998, is a data-driven, outcomes-based, quality-improvement program. It uses a six-step process to promote the translation of research findings into better care for veterans. Special focus is placed on documenting best practices, developing strategies for implementation, and disseminating results and recommendations.

The six basic QUERI steps are as follows:

1. Identify high-risk or high-volume diseases or problems
2. Identify evidence-based clinical recommendations or best practices
3. Define and analyze existing practice patterns and identify, measure and diagnose gaps in quality, performance and outcomes
4. Design and implement interventions to promote best practices
5. Evaluate the effects of interventions on patient, family and health care system outcomes
6. Document that outcomes are associated with improved health-related quality of life

Along with the newly established amputation QUERI, VA supports QUERI programs on nine other serious health conditions that affect large numbers of veterans: chronic heart failure, colorectal cancer, diabetes, HIV/AIDS, ischemic heart disease, mental health disorders (depression and schizophrenia), spinal cord injury, stroke, and substance abuse.

VA, Walter Reed Can 'Lead National Health Care System'
Robert Ruff, MD, PhD, acting director of Rehabilitation Research and Development for VA, said at the workshop that findings from studies by VA and WRAMC should guide national health care policy on amputation and prosthetics. He noted that VA-the largest health care system in the world, with 163 hospitals, 800 clinics and a paperless file-transfer system spanning some 1,300 total points of care-is the nation's strongest resource for outcomes research, rehabilitation research and clinical trials. He stressed that VA services are driven by the definition of best care and not health-insurance constraints.

Dr. Ruff added that VA also cares for a large number of diabetes-related amputees; in fact, diabetes is the leading cause of amputation among veterans. Currently, more than 10,000 amputees are eligible for VA care.

Lt. Col. Paul Pasquina, MD, of WRAMC, provided a comprehensive overview of the care process from battlefield to medical treatment facility to WRAMC, covering a wide range of surgical, medical, rehabilitation and psychosocial issues. He noted, for example, that many of the war-wounded amputees have co-morbidities that present special challenges to the care team: 82 per cent have infections, 68 per cent have soft-tissue damage, 50 per cent have fractures, and 24 per cent have nerve injuries. The overarching goal, he said, is to "provide the highest quality of care to our soldiers, who are willing to put their life in harm's way."

Clinical Groups Paired With QUERI Groups
The first day of the two-day workshop included presentations on current research and care in the area of amputation and prosthetics, with a special focus on the continuum of care from active duty to VA. Also featured was a talk on evidence-based medicine by Mark Helfand, MD, MS, MPH, director of the Evidence-Based Practice Center at Oregon Health and Science University, funded by the Agency for Healthcare Research and Quality.

Central to the morning's presentations was an in-depth overview of the QUERI process from Brian Mittman, PhD, interim associate director for the overall QUERI project. He described the QUERI approach as "outcome- and impact-oriented," and referred to QUERI programs as "centers without walls" that rely on close collaborations among core and field-based staff nationwide. Integral to QUERI, he said, are rapid results, rapid responses, short timelines, and "learning while doing."

Following these presentations, participants broke out into clinical working groups focused on the following topics: access to VA care; prosthetic prescriptions and fitting; amputee rehabilitation; and comorbidities, complications and psychosocial issues. Each group was charged with outlining a complete QUERI process in its area. Later in the day, the clinical work groups met with various QUERI methods groups, each presenting guidelines on different steps within the QUERI process. The clinical groups then reconvened to further develop their outlines, and prepared to present their results the following day.

In exploring how they would implement the QUERI process, and assessing the evidence that already exists, each of the clinical groups forged recommendations for future action. A few examples:

* Establish an amputee database, to include outpatients. The database would include information on functional status and outcomes, and would serve as a reference for clinical staff and a valuable tool for further research.
* Survey and document the amputation-related resources available at each VA medical center, including surgical, prosthetic/orthotic and rehabilitation services.
* Standardize care at intake and through treatment and follow-up. Avoid fragmentation of care, in part by disseminating best-practices information and evaluating implementation at all VA sites, urban and rural.

VA Looking To Fund Additional Research On Amputation
Along with the QUERI workshop, VA has called for research proposals focused on improving outcomes for amputees and prosthetics users. The solicitation is sponsored jointly by VA's Rehabilitation and Health Services research services.

Among the priority areas the solicitation is seeking to address:

* Comparing the cost-effectiveness of different prostheses
* Analyzing how veterans use their prostheses for daily activities
* Studying disorders and risk factors that lead to amputation
* Examining psychosocial factors relating to amputation
* Identifying barriers for amputees reintegrating into military or civilian life
* Developing and evaluating rehabilitation methods

The full solicitation is posted on the VA research Web site at www.va.gov. For additional questions contact Denise Burton, PhD, at (202) 254-0268 or denise.burton@hq.med.va.gov.

Presentations from the Traumatic Amputation QUERI Workshop can be found at www.vard.org/meet/queri/jump.htm.

VA and Walter Reed Army Medical Center will continue to work together in caring for our returning service men and women, with the goal of restoring them to the highest level of independence and functioning possible, and enabling them to lead full, productive lives.

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