Aligning quality improvement, research, and health system goals using the QUERI priority-setting process: A step forward in creating a learning health system

Timely generation and use of research evidence and methods to benefit patients, providers, and health systems continues to be a challenge for many health systems. The Quality Enhancement Research Initiative (QUERI) was established under the Office of Research and Development to help close this gap in the Department of Veterans Affairs (VA) health care system, the largest national integrated health system in the United States, by accelerating the uptake of research findings into health care practice and policy.^{1, 2} QUERI funds investigators embedded in VA health care facilities to partner with multilevel leaders, providers and other frontline staff, managers, and Veterans to scale-up, spread, and sustain promising and evidence-based practices that address the needs of Veterans and the health system.

Each year, QUERI identifies its funding priorities through a systematic process that is grounded in the Learning Health System Framework.³ The development and implementation of this priority-setting process to guide QUERI implementation, evaluation, and quality improvement investments has been described previously.³ Briefly, the QUERI priority-setting process involves engaging leaders across the VA to identify their top priorities, funding initiatives to address these priorities, and communicating the results and impacts of these initiatives to VA leaders and other interested/impacted groups. The success of the QUERI priority-setting process is evidenced by its adaptation by the VA Office of Research and Development, which uses QUERI's process to identify VA research priorities with the goal of ensuring VA research is aligned with health system and Veteran needs.

The goal of this commentary is to describe the application of QUERI's priority-setting process to identify Veteran-centered research priorities for chronic pain and opioid use disorder (OUD). The four-step process involves identifying research gaps and priorities through an environmental scan, incorporating input from various interested parties and impacted groups, finalizing priorities through an executive committee, and integrating the priorities into funding announcements.

The first step involved assessing the current state of research on OUD and chronic pain through reviewing reports, journal articles, strategic plans, and websites. This rapid environmental scan included evidence from across the research translation spectrum and was conducted over a period of 1 week in February 2023. A list of research gaps and priorities were identified based on evidence needs documented in VA (e.g., FY2022-FY2028 VA Strategic Plan,⁴ VA Health Systems Consortium of Research focused on pain/OUD [VA Pain/Opioid CoRE]⁵) and other agency reports (e.g., Surgeon General's Report on Alcohol, Drugs, and Health⁶; National Institute of Health's Early-Phase Pain Investigation Clinical Network research program's focus areas⁷), research literature, and white and gray literature. In addition, the lead scientific program managers for the chronic pain and opioid portfolio analyzed the portfolio to identify ongoing and unpublished VA research studies.

Some of the initially identified research gaps included clinical studies of the biological bases of pain and OUD; preclinical studies of non-opioid pain therapies; intervention research to improve outcomes in OUD care; studies correlating subjective pain measures and objective functional outcomes; research on risk, prevention, and treatment of OUD; and studies of environmental and policy interventions to address social determinants of OUD.

The second step involved gathering input from multilevel VA clinical operations leadership, providers and frontline staff, Veterans, and researchers to understand the needs of Veterans and the VA health care system. In early March 2023, the list of pain and OUD priorities generated in Step 1 was refined based on input from VA Chief Medical Officers, Chief Nursing Officers, and Chiefs of Staff (Table 1). Then, between March 2023 and May 2023, the refined list was presented to groups for input and prioritization (Table 2). Several groups were provided information about the priorities and polled live during their regularly scheduled meetings: Chiefs of Staff of VA facilities; the VA National Pain Management Strategy Coordinating Committee, an interdisciplinary group of clinicians and operations leaders with pain management implementation and dissemination oversight; Patient Aligned Care Team Pain Champions, including representatives from VA facilities across the country working to improve pain care in primary care settings; and Veterans Integrated Service Network Pain Consultants who support regional implementation of effective pain care. The VA National Substance Use Disorder Community of Practice was provided information about the priorities and given a link to a questionnaire to submit their rankings during a regularly scheduled meeting. Focus groups and live polling were conducted with three Veteran Engagement Councils made up of Veterans with lived experience with pain, OUD, and/or substance use disorder. Finally, questionnaires were distributed via e-mail to a group of pain and OUD providers identified by the VA Pain Management, Opioid Safety, and Prescription Drug Monitoring Program office and a group of pain and OUD researchers identified by the lead scientific program managers of the VA Office of Research and Development Pain/OUD Research Portfolio. The VA Pain/Opioid CoRE, a research center funded by VA Health Systems Research that works to enhance collaboration and accelerate research related to pain and OUD, supported the process by rephrasing the research gaps in lay language and providing a high-level summary of basic, clinical, and health services research. This provided respondents with a real-world sense of the meaning and value of these different stages. Participants were asked to select the two priorities in basic and clinical research and the two priorities in health services and policy research they felt were most urgent, feasible, and impactful.

Priorities ranked highly by all categories of groups (i.e., VA leaders, providers, Veterans, and researchers) included identifying new therapeutic targets for pain, tolerance, and/or OUD and clinical treatments for long-term recovery from pain, especially non-opioid treatments. Priorities ranked highly by at least three of the categories of groups included environmental, social, and policy changes addressing social determinants to prevent opioid misuse; implementation of treatments and approaches to enhance pain treatment services, especially for underserved groups; and research on the risk factors, treatment, and prevention of OUD.

The list of priorities was further refined by an expert committee of pain and OUD experts from research and clinical operations, developing specific language consistent with requests for funding applications. In July 2023, a meeting was held with scientific and operational leaders with expertise in pain and OUD to discuss the results of steps 1 and 2 and an updated portfolio analysis of existing research within VA. Specific areas of work within each priority area were articulated by subcommittees made up of a scientific program manager leading the portfolio, a representative from a relevant VA national program office, and subject matter experts and then areas of work were voted on by the larger group. For example, in relation to the priority of risk, treatment, and prevention of OUD, one group discussed identifying behavioral and genetic risk factors for high impact chronic pain as a focus for future research. Within the new therapeutic target priority, the group identified studies of xylazine reversal medications as an area of special emphasis for future research. Within the policy change priority, the group discussed studies of harm reduction services and treatment programs that reduce pain medication use but do not require abstinence.

The fourth step of the prioritization process was to operationalize the selected priorities into funding opportunities for research. The final priorities were incorporated into the VA Office of Research and Development's broad funding announcements as emphasis areas and specialized funding announcements. During the research funding cycle following this process, 11 applications were received in response to Requests for Applications related to these priorities. Based on scientific merit and programmatic review, five of the applications were funded. These studies include a study to address spinal targets to treat persistent bladder pain, an emulated trial to improve pain and reduce long-term opioid use among Veterans, a randomized study of auricular neuromodulation in Veterans with fibromyalgia, a study of the efficacy of cognitive behavioral therapy for chronic pain with Veterans with serious mental illness, and a trial of pain management teams using Whole Health (a patient-centered, integrated care approach⁸) to optimize function and safety in Veterans. As studies are funded and underway, their progress and ongoing impacts will be assessed to inform the next iteration of pain and OUD research prioritization.

The application of QUERI's process to identify, refine, and integrate research priorities for chronic pain and OUD helps synchronize research efforts with clinical and organizational needs. Grounded in the Learning Heath System Framework with a participatory emphasis, this approach to setting research priorities involves integrating knowledge from within the organization with external evidence and gathering feedback from multilevel partners and end users.⁹ The iterative, cyclical nature of the approach and incorporation of a wide range of perspectives facilitates a common understanding of the health care system's needs that is required for continuous improvement.¹⁰ In particular, the incorporation of Veteran perspectives ensures the priorities are Veteran-centered, and Veterans who participated in the process expressed their appreciation for the opportunity to help shape research priorities.¹¹

Key strengths of the process include the flexibility to apply it to different research and strategic operations areas, the incorporation of multiple perspectives, the integration of a range of evidence from across the research translational spectrum, and the more rapid nature of the process (4 months) to ensure that research is supporting health system needs in a timelier manner. The process helps align researchers, providers, Veterans, and clinical operations leaders around common priorities and goals and further supports VA's transformation to a Learning Health System.¹² Beyond the pain and OUD research area, this process is being applied to other VA Office of Research and Development portfolios and other areas of VA. VA QUERI's Center for Evaluation and Implementation Resources is working with the VA Office of Enterprise Integration to apply the process to identify Veteran-centered priorities to include in VA's next Strategic Plan.

While this rapid approach allowed for timely incorporation of diverse perspectives into VA research priorities, a trade-off is the limited information that could be gathered in the environmental scan and from the groups who provided input. The environmental scan was, by design, not as extensive as a systematic literature review, leading to the potential that some priority areas were missed or others were overemphasized. Live polling and questionnaires only asked for responses directly related to ranking the priorities, preventing the ability to confirm representativeness of the sample or make additional useful inferences such as regional patterns in priorities. This highlights the importance of iteration on the process as it is adapted to new research topic areas and as pain and OUD priorities are updated in the future.

The application of the QUERI priority-setting process to identify research priorities helps foster the integration and alignment of research, implementation/evaluation, and quality improvement efforts with health system operations, priorities, and goals.¹³ This priority-setting process can serve as a model for how research institutions and health care organizations can align their research priorities with patient and community needs.

This work was supported by the US Department of Veterans Affairs, Veterans Health Administration, Health Services Research, Quality Enhancement Research Initiative. The views expressed are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US Government.

The authors declare no conflicts of interest.