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How does VA research differ from that carried out in other academic hospital settings?

Credit: Department of Veteran Affairs

It's a government-funded, intramural research program embedded in the health system, and that's pretty unique. I don't think there's any other program that funds such a broad spectrum of research, from basic to clinical, that's actually part of a healthcare system. Our researchers collaborate every easily—more easily than I have ever seen. And the modest size enables us to set up little programs and centers of excellence fairly quickly. There's an intangible quality to VA research that people even in it don't realize. You almost have to come from the outside to see it.

How does the VA determine how to allocate its annual $590 million medical and prosthetic research budget?

We have to always strike a balance between deployment-related conditions and illnesses that everybody has. But we certainly put a priority on wartime injuries and service-related conditions. For example, mental health is almost 20% of our portfolio—it's the largest thing we do—with research into post-traumatic stress disorder, drug abuse, depression and other post-deployment mental health issues. For this war, traumatic brain injury is considered the signature injury, so we've ramped up our program there. The Secretary of the VA has also made homelessness a major thing, so we've built a program there over the last year and a half.

The VA Healthcare Network has had an electronic health record system in use for longer than most hospitals in the country. How do investigators incorporate these electronic records into their research?

We use the electronic health record in many ways. In research directly, we identify patients who might be candidates for research, we can follow up patients long term after trials and we can also compare therapies. We've done a number of projects where we just take an event and see what happens both before and after as a basis for further research. For example, we looked at suicides for those veterans who were in the VA healthcare system to see what type of care they got beforehand and whether they had a mental health diagnosis. We found that men with bipolar disorder and women with substance use disorders were at particularly elevated risk for suicide. So it has many uses, and of course with the Million Veteran Program it's going to have a very extensive and now much more enhanced use than it ever has.

What else has prepared the VA to launch an effort on this large scale?

We have a research program with very-high-caliber investigators embedded in a healthcare system. We also have a cohort of veterans who are, in general, an altruistic population, who do things out of service and to help other people. And we have also built an infrastructure for this—we built a pharmacogenomics laboratory, we have a large biorepository, we have information technology platforms and we have a central IRB—all of which is very important because this is going to be almost universal across the VA Healthcare System, and that really makes it possible.

Based on the pilot project launched in January at the VA Boston Healthcare System, how is the initiative proceeding thus far?

We spent a lot of preparatory time with this, and the enrollment has been good. As you can imagine, it's a huge logistic effort, and I think it's gone quite well. In fact, the only thing that didn't go well was there was a major snowstorm the first week, so it delayed some things, but I don't know of anything that's come out from these preliminary studies that would alter our course in any way. We're still in the early phases, mind you. It's now in nine hospitals, and pretty soon it's going to expand in another 17 and grow out from there. We hope to be up to a million veterans in five to seven years, and with the rate of recruitment it looks like we'll get there.

You've spent most of your career at universities and teaching hospitals. What lured you to the VA?

Over two thirds of physicians [in the US] at some point train at a VA hospital, but I never did. And while I was in medical schools that had affiliations with VA hospitals, I wasn't that close to them at the time. But I've always known about VA research and had a great respect for it. So I embraced the opportunity to run a research program that helps veterans, which I feel strongly about, while also having general importance to the public at large.