The past, present, and future of comparative effectiveness research in the US Department of Veterans Affairs.

A particular challenge for the healthcare provider and the patient is to choose among competing therapeutic approaches for a particular condition. Often, the relative benefits and risks of potential therapies are not uniformly available from the existing scientific information. Many have pointed to the need for more comparative effectiveness research (CER) to aide in these decisions. The US Department of Veterans Affairs (VA) has a long history of conducting CER. The success of the VA CER program has been facilitated by several important aspects of scientific infrastructure related to (1) research question refinement, (2) study design, planning and coordination, (3) evidence synthesis, and (4) implementation research. In publications that had VA coauthors in 2 major medical journals, 25% of the published studies were classified as CER. The most frequent categories of study were pharmaceutical and behavioral interventions. In the future, the CER enterprise will move toward increased input from clinicians in research topic choice and enhanced consideration of other methodologies besides the randomized controlled trial.

Quantitive imaging in late traumatic brain injury. Part I: late imaging parameters in closed and penetrating head injuries.

OBJECTIVE: To ascertain the value of relatively simple quantitative radiologic measurements after head injury. Despite major advances in neuroradiology, analysis and reporting of imaging studies is based primarily on individual subjective and local experience, rather than on reproducible, standardized parameters; reliance on newer technologies can improve care, but also raises diagnostic costs. DESIGN: Blinded, retrospective, quantitative assessment of computerized tomography studies done some 14 years post-injury. OUTCOME MEASURES: Frontal horn width (FHW); septum-caudate distance (SCD); temporal horn width (THW); interuncal distance (IUD); third ventricle width (3VW); ventricular score (VS); sulcal width (SW); gray-white matter discriminability (GWMD) and subjective assessment of atrophy (SAOA). RESULTS: Diffuse and frontal damage was noted in both closed (CHI) and penetrating (PHI) head injury groups. Enlargement of frontal lobe parameters (septum caudate distance and frontal horn width suggest frontal injury in both closed and penetrating traumatic brain injury (TBI). Temporal horn width and inter-uncal distance were related to VS, 3VW and FHW in closed, but not in penetrating head injury. CONCLUSIONS: Simple linear CSF space measurements are correlated with volumetric and parenchymal measures, and can represent valuable and reliable low-cost quantitative measures of long term brain damage after TBI.

Quantitative imaging in late TBI. Part II: cognition and work after closed and penetrating head injury: a report of the Vietnam head injury study.

CONTEXT: Functional outcome in relation to CT findings in traumatic brain injured (TBI) patients is not well established in relation to cognitive and vocational outcome. OBJECTIVE: To investigate the possible correlation between relatively simple quantitative radiological measurements and cognitive and vocational outcome. DESIGN: Retrospective analysis of quantitative assessment of CT studies in relation to post-injury cognitive changes and vocational outcome. SETTING: US Army Medical Centre. PATIENTS: 74 penetrating head injured (PHI) and 37 closed head injured (CHI) Vietnam war veterans. OUTCOME MEASURES: The Armed Forces Qualification Test (AFQT); Disability score; Return to work. RESULTS: Total brain volume loss, third ventricle width (3VW), ventricular score (VS), and septum-caudate distance (SCD) were significantly related to cognitive change and return to work in PHI patients. Volume loss and 3VW were the most valuable radiologic predictors of outcome in multivariate linear and logistic regression models for both CHI and PHI. CONCLUSION: 3VW on late CT scans following traumatic brain injury is a powerful predictor of overall long-term cognitive outcomes and potential for return to work.