Veterans Health Administration Research in Aging: Opportunities for High Impact Across the Academic Career

Introduction

Almost half of the nine million U.S. Veterans enrolled in the Veterans Health Administration (VHA) are aged 65 and older, with close to 1.2 million > 85 years old.¹ Because VHA’s mission is to provide exceptional life-long health care to Veterans, VHA was among the first health systems to integrate innovative research and discovery with clinical program delivery to advance interdisciplinary, evidence-based programs to address the unique health care needs of older adults.

VHA health systems with active research programs foster the professional careers of investigators at all levels through long-standing affiliations with major research universities, facilitating export of innovations from VHA to the broader U.S. population. Integral to clinical care, the majority of physician trainees in the U.S. receive part of their training within VHA.² With substantial investment over the past two decades to develop a robust national data infrastructure and cooperative network of clinical study sites, a research career within the VHA is conducive to high impact discoveries that address the most pressing health care needs of older Veterans and non-Veterans. In this special commentary, we highlight VHA’s unique strengths and training opportunities for investigators to catalyze studies along the translational science pipeline from foundational science in aging to clinical care for older adults at a national level.

VA Research is Embedded Within an Integrated Health System

Paired with VHA’s $1 billion annual research operation, VHA’s integrated health system has become a learning healthcare system, with research encompassing the full translational range, from basic and pre-clinical research to informing population health.^3,4 This model has specific benefits for conducting aging-focused research. First, VHA is a leader in developing and testing novel models of care to optimize older adults’ health and wellbeing across care settings.^5–7 Second, VHA is a leader in translating scientific discoveries and integrating technology into the care of older Veterans and the advancement in telehealth allows for the delivery of evidence-based telehealth delivery to Veterans living in rural settings.⁸ Third, implementation and dissemination of these innovations occurs more rapidly within VHA’s integrated health system and has greater opportunity for national impact. VHA’s robust implementation science from partnerships between VHA clinical care and the Office of Research & Development (ORD), including the Quality Enhancement Research Initiative, has expanded the dissemination of evidence-based care models focused on improving functional status and quality of life for older Veterans, including programs to increase mobility among hospitalized older adults, enhance patient-centered care in VHA nursing homes, and reduce low-value medication use in primary care.⁴

Availability of National Data Infrastructure and Cooperative Clinical Study Sites to Promote Implementable Research

Substantial VHA investments in research infrastructure have created distinctive opportunities for trainees and early and senior career VHA investigators. VHA’s Office of Information & Technology built the VHA clinical data warehouse (CDW) to enable comprehensive analysis of healthcare services.⁹ Outpatient and inpatient clinical data, long-term services, and administrative data are combined by standardizing, consolidating, and streamlining clinical data systems. CDW currently includes all categorical and quantitative clinical indices, medications, and equipment. Moreover, metrics pertaining to caregivers and physical function will soon be added. To improve researcher access to the CDW while ensuring Veterans’ privacy and data security, the VA Informatics and Computing Infrastructure (VINCI) was developed.

The Geriatrics and Extended Care (GEC) Office’s Data & Analysis Center (GECDAC) builds upon CDW by adding data sources including Medicare, Medicaid, the Minimum Dataset (MDS), Outpatient and Ambulatory Surgery, and subacute care.¹⁰ The Million Veteran Program (MVP) is a national research program that links genetic data with lifestyle and military exposures to assess the impact on health and illness. Since launching in 2011, over 900,000 Veteran partners have joined MVP.¹¹ The Centralized Interactive Phenomics Resource (CIPHER) is a data repository of clinical phenotypes designed to link MVP-based genetic data to Veterans’ health supported by MVP (under the aegis of ORD), Cooperative Studies Program (CSP),¹² and VINCI.¹³ CIPHER catalogs and integrates VHA electronic health record (EHR)-based phenotype algorithms, definitions, and metadata to provide a phenotype annotation library with an online user-interface, which can be used to distinguish distinctive population phenotypes (e.g., sarcopenia, frailty, cognitive impairments).¹⁴

To bridge research results to clinical care, ORD has been shifting toward an enterprise approach that leverages capabilities, while also facilitating partnerships within VA and with other federal and industry partners to enhance VA investigators’ work and opportunities. The VHA network of clinical research sites such as those engaged in the CSP program or Geriatric Research, Education, and Clinical Center (GRECC) sites provide a growing national resource for older Veterans to participate in studies that directly inform clinical care paradigms. A recent example is the PREVENTABLE trial, which is enrolling the largest U.S.-based cohort of adults aged 75 and older in a randomized clinical trial.¹⁵ To improve cancer care, The National Cancer Institute and Department of Veterans Affairs Interagency Group to Accelerate Trials Enrollment (NAVIGATE) partnership facilitates Veteran access to new investigational therapies.

Funding Mechanisms to Start and Sustain a VA Research Career in Aging or Geriatrics

VHA’s research program offers multiple funding mechanisms to train and build the pipeline of future investigators. GRECCs provide advanced fellowship programs for post-doctoral trainees from clinical disciplines. Other unique post-doctoral fellowship programs focused on specialized research methods (e.g., Big Data, Health Services Research/Learning Health Systems) can be launching pads for research focused on addressing needs of older adults.

Mentored Career Development Awards (CDAs) are supported across all areas of the VHA ORD research enterprise, spanning preclinical, clinical, rehabilitation, and health services research. Importantly, even though VHA is an intramural research program, CDA applicants do not need to have a VHA appointment before they apply, to facilitate recruitment of talented investigators within and outside of VHA.

There are similarities between VHA’s CDA program and research CDAs sponsored by NIH institutes (commonly known as K awards). In one study of academic advancement and productivity of CDA recipients from ORD’s Health Services Research and Development (HSR&D), NIH, and the Agency for Healthcare Research and Quality (AHRQ), all three programs were successfully selecting and mentoring awardees.¹⁶ Following completion of their career award, ORD HSR&D CDA recipients reported being principal investigators on more large grants and had a higher mean number of major journal articles than K awardees.¹⁶ ORD CDAs may have particular advantages for certain types of clinician investigators such as surgeon scientists, given the challenges of managing the required protected research time with the financial limits of K awards.¹⁷

Funding mechanisms within ORD include parent announcements for pilot, merit (i.e., larger investigator-initiated), and career awards plus Requests for Applications (RFA)’s in specific research priorities areas. For example, aging and long-term care is a designated research priority for health services research studies. Recent topics of specific interest include examining care for older Veterans in non-institutional settings and whether enhanced care allows more older Veterans to age in place.¹ Caregivers, long-term care, and non-institutional care for Veterans are also emphasized given the expansion of eligibility for the comprehensive family assistance to caregivers under the MISSION Act.¹⁸ ORD also supports collaborative initiatives such as the National Plan to Address Alzheimer’s Disease to accelerate the development of treatments, improve early diagnosis and coordination of care, and reduce ethnic and racial disparities in rates and burden of dementia. Additionally, many VHA facilities have an affiliated VA research foundation, a not-for-profit research corporation, that allows VHA investigators to leverage funds from private companies, donors, NIH, other government agencies, and academic institutions, for VHA specific research.

To demonstrate the potential for scientists across disciplines to develop a career in aging research within VHA, we conducted an evaluation of CDAs focused on aging research within the four ORD research service areas. Data from a ten-year period (fiscal years 2011–2020) were extracted using the VHA ORD Research Analysis and Forecasting Tool software and identified by the Designated Research Area classification coding pertaining to aging or older Veterans’ health and care. Verification occurred through review of project abstracts for terms such as aging, age-, older, age 65 or 85 and older, geriatrics, psychogeriatrics, neurodegeneration, biogerontology, gerontology, and geroscience. Subsequent federal funding was identified through eRA Commons (administrative online interface). This evaluation revealed that awards focused on aging were well-represented across all areas of VHA research. In the ten-year period, 581 CDA’s were awarded, with 182 (31%) focused on aging research. Remarkably, 64% of the investigators with a completed CDA went on to receive a subsequent ORD or NIH award. See Figure 1 for breakdown across disciplines (Figure 1).

Figure 1: Proportion of Career Development Awardees with Aging Focus Awarded Subsequent Federal Funding (started and completed CDA between January 2011 – September 2020).

BLRD (Biomedical and Laboratory Research & Development): n=35 CDAs completed in aging

CSRD (Clinical Science Research & Development: n=28 CDAs completed in aging

RRD (Rehabilitation Research & Development): n=32 CDAs completed in aging (does not include CDA-1 mechanism)

HSRD (Health Services Research & Development): n=23 CDAs completed in aging

Finally, to maximize the sustainability of the VHA research enterprise, non-clinician investigators who have made extraordinary contributions to VHA research may be eligible for a Research Career Scientist (RCS) award. In the ten-year period, 200 RCS awards were granted with78 (39%) focused on aging research.

In conclusion, we highlight the immense resources available within VHA to advance understanding of aging and best practices in the care of older adults. Additionally, VHA offers tremendous opportunities for a successful career in aging and geriatrics research across scientific disciplines and in synergy with academic affiliates and other federal funding partners.