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.