Addressing the Science-Practice Gap: Evidence Synthesis & Dissemination of Mental Health Care Topics in the Military Health System

Bradley Belsher, PhD¹,2; Daniel Evatt, PhD¹,2; Lindsay Stewart, BA1; Erin Beech, MA1; Marina Khusid, MD3; Susanne Hempel, PhD4; Jean Otto, DrPH¹,2; Abigail Wilson, PhD ¹,5; Don Workman, PhD¹,2; Marjorie Campbell, PhD¹,2 1Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Silver Spring, MD; 2Uniformed Services University of the Health Sciences, Bethesda, MD; 3Office of the Chief of Staff, Jesse Brown VA Medical Center, Chicago, IL; 4RAND Corporation, Santa Monica, CA; 5George Washington University, Washington, DC.

To support knowledge translation and dissemination within the Military Health System (MHS) and promote evidence-based practices, the Deployment Health Clinical Center (DHCC) established an

evidence synthesis and dissemination (ES&D) capability. This multi-phased effort is described below, concluding with a listing of current products and brief discussion of next steps.

Phase I: Enhance team knowledge and expertise in evidence synthesis methodologies, and develop a suite of evidence synthesis products.

Phase II: Develop standard processes to solicit stakeholder input. This includes giving the general public the opportunity to submit and vote for topics for Psych Health

Evidence Briefs, as well as the creation of a topic nomination form for rapid reviews, systematic reviews, and evidence maps, which has been presented to key stakeholder groups.

Phase III: Refine and sustain existing ES&D capabilities. DHCC ES&D is collecting stakeholder feedback and identifying additional ways to measure the impact

and reach of our products. As visibility of ES&D capabilities increases across the MHS, efforts are focused on streamlining internal processes to most effectively and efficiently prioritize pertinent topics

and team resources.

Establish Evidence Synthesis Capability

Existing evidence synthesis centers were identified to gain insights about expertise and resource requirements th at would enable DHCC to stand up an Evidence Synthesis and Dissemination (ES&D) team. • Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Centers (EPC) • Department of Veterans Affairs E vidence-based Synthesis Program (VA ESP)

ES&D team members completed in-person skill-building workshops and online training programs to develop skills in evidence synthesis methodologies. • Cochrane approach to conducting systematic reviews • GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to

evaluating quality of evidence

The team secured a collaborative p artnership with RAND Evidence-based Practice Center (EPC) to minimize potential biases in conducting systematic reviews.

The Systematic Review Process

Frame the Question

PICO[TS] Key Questions

Devise the Search Strategy

Databases Gray Literature

Screen and Select S tudies

Eligibility Crit eria

Summarize the Evidence Data Extraction and Synthesis

Risk of Bias

Interpret the Findings

Summary of Findings Tables

Strength of Evidence

ES&D Products of Varying Scope

The goal of DHCC ES&D is to use systematic, rigorous, and transparent methods to produce various types of evidence synthesis reports that can inform and promote evidence-based psychological health

practices and policies in the Military Health System (MHS).

Psych Health Evidence Briefs Rapid Reviews Systematic Reviews

Ai

m

To inform patients and providers about the current evidence base and clinical

guidance for specific treatments.

To inform time-sensitive health care decisions that are not

addressed in existing VA/DoD clinical p ractice guidelines

(CPGs) or reviews.

To inform VA/DoD CPGs and MHS policy decisions by

identifying evidence-based health care practices.

ope

Sc

“Is [treatment] recommended for treating [disorder]?”

Narrow eligibility criteria an d search strategy

Summary of evidence base and clinical guidance

No critical appraisal

Limited number of key questions and outcomes of

interest

Narrow eligibility criteria an d search strategy

Summary of evidence; may include qualitative synthesis

Critical appraisal of individual studies

Comprehensive key questions and outcomes of interest

Broad, pre-defined eligibility criteria and search strategy

Qualitative and/or quantitative synthesis; may include meta-

analysis

Assessment of quality and strength of evidence

e Ti

m Days – Weeks to complete

Weeks – Months to complete

Months – Years to complete

Devise ES&D Topic Selection Processes

Developing communication channels to solicit feedback from MHS stakeholders i s an essential component to this effort to ensure we continually address relevant topics and provide useful information.

Psych Health Evidence Brief Topics Stakeholders may submit topic ideas using a suggestion box on the DHCC website. Each quarter, submissions are compiled and supplemented with trending topics identified by Google News.

Ten topics are posted on the website to be voted on throughout the quarter. The five topics receiving the most votes are selected for development.

Systematic Review Topic Nominations MHS stakeholder groups are briefed about DHCC ES&D efforts and capabilities to solicit nominations for evidence synthesis reports.

All requests from MHS leaders and decision-makers are reviewed and prioritized based on information provided in the ES&D Topic Nomination Form. The nomination form ensures that essential details are captured in the request and properly discussed with the stakeholder during refinement.

ES&D Selection Criteria informs whether a topic

is selected and the appropriate evidence

synthesis methodology.

Appropriateness Importance

Not duplicative Feasibility

Impact

Brief background search

Existing VA/DoD CPGs and other clinical guidance

Existing high-quality systematic reviews

Psych Health Evidence Brief

Rapid Review

Systematic Review

Topics that are nominated by stakeholders are evaluated to determine the appropriate line of effort.

Next Steps – Measure Impact

Product Impact Metrics • Surveys are included on the Psych Health Evidence Briefs webpage to solicit readers’ feedback. • A user-feedback survey is being implemented to assess the applicability, acceptability, and

usability of ES&D reports that are produced in response to MHS stakeholder topic nominations.

Refine ES&D Processes • ES&D will utilize user feedback, as well as internal lessons-learned to refine and further

streamline topic selection and product development processes.

Disseminate ES&D Products

Psych Health Evidence Briefs

Fifteen Psych Health Evidence Briefs have been produced and posted on the DHCC website, including treatments for posttrau matic stress disorder (PTSD), major depressive disorder (MDD), and alcoho l/substance use di sorders (AUD/SUD). Recent briefs include: • Acceptance and Commitment Therapy for MD D • Cannabis for PTSD • Emotional Freedom Technique for PTSD • Problem-Solving Therapy for MDD • Short-term Psychodynamic Psychotherapy for MDD

Rapid Reviews

Rapid reviews are produced by implementing strate gic alterations to the systematic review methodology, which aim to minimize the introduction of bias while addressing time-sensitive evidence synthesis questions.

In response to a stakeholder request with a one-month timeline, we recently conducted our first rapid revie w: • Outpatient Behavioral Health Provider Panel Size and

Burnout in the Military Health System (MHS)

Systematic Reviews & Evidence Maps

DHCC is sponsoring a series of systematic reviews con ducted by the RAND EPC to identify and address gaps in psychological health care:

• Series 1: 10 reports focused on complementary and alternative medicine (CAM) interventions for PTSD, MDD, SUD, and chronic pain.

• Series 2: 5 reports are underway, including system atic reviews and evidence maps of psychological health research that address gaps in p ractice.

In-progress internal products include: • “Present-centered therapy (PCT) for posttraumat ic stress disorder (PTSD) in adults,” a Cochrane

systematic review • “Gambling Disorder and Problem Gambling: An Evidence Map“

REFERENCES

1. Hartling L, Guise J-M, Kato E, Anderson J, Belinson S, Berliner E , et al. (2015). A taxonomy of rapid reviews links report types and methods to specific decision-making contexts. J Clin Epidemiol, 68(12), 1451–62.

Collaborators and related organizations: 1. Evidence-based Practice Centers (EPC) Program of the Agency for Healthcare Research and Quality (AHRQ) 2. Cochrane 3. GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 4. RAND Southern California Evidence-based Practice Center (EPC) 5. VA Evidence-based Synthesis Program (ESP)

The views expressed in this presentation are those of the authors and do not necessarily represent the official policy or position of the DoD Deployment Health Clinical Center, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Department of Defense, Uniformed Services University of the Health Sciences, or any other organization public or private. www.pdhealth.mil PUID 4394