De-Intensifying Unnecessary Medications in VA CLC Residents Nearing End of Life

减少对临近生命终点的 VA CLC 居民不必要的药物治疗

• 批准号: 10186480
• 负责人: Carolyn Timberlake Thorpe
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-05-01 至 2021-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10186480
• 关键词: Address; Admission activity; Adoption; Adult; Advanced Development; Affect; Area; Benefits and Risks; Blood Pressure; Caregivers; Caring; Chronic; Chronic Disease; Clinical Data; Consensus; Coronary Arteriosclerosis; Data; Data Set; Diabetes Mellitus; Disease; Elderly; Emergency Situation; Emergency department visit; Ensure; Equilibrium; Event; Family Caregiver; Geriatrics; Goals; Guidelines; Hospital Departments; Hospitalization; Hypertension; Internal Medicine; Intervention; Interview; Life; Life Expectancy; Link; Lipids; Long-Term Care; Maps; Measurement; Medicare claim; Medication Management; Methods; Nursing Homes; Outcome; Palliative Care; Patient Preferences; Patients; Pattern; Performance; Pharmaceutical Preparations; Phase; Population; Practice Guidelines; Probability; Provider; Quality of Care; Recommendation; Records; Reporting; Research; Research Design; Research Priority; Sampling; Scoring Method; Selection Bias; Structure; Time Study; United States National Institutes of Health; Variant; Veterans; Visit; Weight; advanced dementia; adverse drug reaction; adverse event risk; base; care delivery; care systems; caregiving; community living; disorder risk; editorial; end of life; end of life care; experience; glycemic control; high risk; implementation facilitation; improved; informal caregiver; insight; intervention mapping; multiple chronic conditions; outcome prediction; pharmacy benefit; preference; shared decision making; standard of care; therapy design; therapy development; tool; treatment guidelines; uptake

 DESCRIPTION (provided by applicant): The long-term goal of this research is to improve the quality of care provided to VA Community Living Center (CLC) residents with limited life expectancy (LLE) and/or advanced dementia (AD), through the safe and effective use of medication that is aligned with their goals of care. In the years leading up to the development of AD and other life-limiting conditions, most CLC residents have accumulated multiple chronic conditions requiring medication therapy (e.g., coronary artery disease, hypertension, diabetes). However, practice guidelines developed for general adult populations calling for intense treatment of these conditions may no longer be appropriate for residents with LLE/AD, given reduced potential to live long enough to experience benefits and higher propensity for adverse drug reactions. Several geriatric groups have issued recommendations for intense chronic disease treatments to avoid in patients with LLE/AD, but these recommendations have not been consistently integrated into VA or other disease-specific guidelines and their adoption in CLC practice is unknown. These LLE/AD-specific recommendations are also largely based on expert consensus about hypothesized risks and benefits, rather than direct evidence about actual risks and benefits from rigorously designed studies with LLE/AD patients. The lack of direct and specific evidence about this risk/benefit balance hinders the ability of Veterans, their informal caregivers, and VA providers to make informed, shared decisions that are aligned with Veterans' goals of care. In partnership with the VA Office of Geriatric and Extended Care Services (GEC), VA PROMISE Center (Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-Life), VA Pharmacy Benefits Management (PBM), and CLC clinicians, we propose a mixed-methods study to understand variation in and outcomes of intense vs. de-intensified treatment in Veterans admitted to a CLC and develop an intervention toolkit to serve as the basis for quality improvement (QI) efforts. Specific aims are to (1) describe patterns of receipt of intense vs. de-intensified treatment for lipid, blood pressure (BP), and glycemic control in Veterans with LLE/AD after CLC admission; (2) examine effects of intense treatment for lipid, BP, and glycemic control after CLC admission on all-cause negative events and disease-specific hospitalizations and emergency visits in Veterans with LLE/AD; and (3) using semi-structured interviews with providers and family caregivers and an established intervention mapping framework, identify key barriers and facilitators to implementing LLE/AD-specific recommendations and design an intervention toolkit to serve as the basis for QI efforts. For quantitative aims 1-2, we will link Minimum Dataset (MDS) assessments, PBM medication records, VA utilization/clinical data, and Medicare claims to examine variation across CLCs in intense vs. de-intensified treatment; identify patient, caregiver, provider, and facility factors contributing to this variation; and determine effects on all-cause and disease-specific negative events. Our analytic approach involves propensity score methods with inverse probability of treatment weights to address potential selection bias and confounding. Using results from Aim 1 to purposively sample from CLCs with lower proportions of intensely treated residents ("early adopters" of LLE/AD recommendations) and higher proportions of intensely treated residents ("late adopters"), qualitative Aim 3 will involve semi-structured interviews with providers and family caregivers of recently deceased CLC residents. With input from our partners, we will use these data to map key barriers and facilitators to implementing LLE/AD-specific recommendations and develop an intervention toolkit that will serve as a basis for QI efforts. This study addresses the HSR&D Priority Area on Long-Term Care and Caregiving and Strategies 1-3 of the VA Blueprint for Excellence. It will have significant impact by providing VA with critical information and tools needed to optimize QI efforts to facilitate implementation of LLE/AD-specific treatment recommendations and support improved shared decision-making about medications in CLC residents near end-of-life.

 描述（由申请人提供）： 这项研究的长期目标是通过安全有效地使用与护理目标保持一致的安全有效使用，提高了预期寿命（LLE）和/或高级痴呆症（AD）的弗吉尼亚州社区生活中心（CLC）居民提供的护理质量。在 大多数CLC居民累积了需要药物治疗的多种慢性疾病（例如冠状动脉疾病，高血压，糖尿病），大多数CLC居民累积了多种慢性病。但是，针对要求对这些疾病进行严格治疗的一般成人人群制定的实践指南可能不再适合LLE/AD的居民，鉴于潜力降低了足够长的时间以体验不良药物反应的益处和更高的希望。几个老年群体已经发布了有关LLE/AD患者的强烈慢性疾病治疗的建议，但是这些建议尚未始终纳入VA或其他特定于疾病的指南中，并且在CLC实践中的采用尚不清楚。这些LLE/特定的建议也主要基于有关假设风险和收益的专家共识，而不是直接证明与LLE/AD患者进行严格设计的研究有关的实际风险和收益。缺乏有关这种风险/福利余额的直接证据，阻碍了退伍军人，非正式护理人员和VA提供者做出与退伍军人的护理目标保持一致的知情，共同决定的能力。 In partnership with the VA Office of Geriatric and Extended Care Services (GEC), VA PROMISE Center (Performance Reporting and Outcomes Measurement to Improve the Standard of Care at End-of-Life), VA Pharmacy Benefits Management (PBM), and CLC clinicians, we propose a mixed-methods study to understand variation in and outcomes of intens vs. de-intensified treatment in Veterans admitted to a CLC and develop an intervention工具包可以作为质量改进（QI）工作的基础。具体目的是（1）描述接受脂质，血压（BP）的强化与去授予治疗的接收模式，在CLC入院后患有LLE/AD的退伍军人中的血糖控制模式； （2）CLC入院后对脂质，BP和血糖控制的强烈治疗对全因事件和疾病特异性住院以及LLE/AD退伍军人的紧急拜访的影响； （3）使用对提供者和家庭护理人员的半结构化访谈以及既定的干预映射框架，确定关键的障碍和促进者来实施LLE/特定的建议建议，并设计一个干预工具包，以作为QI工作的基础。对于定量目的1-2，我们将将最低数据集（MDS）评估，PBM药物记录，VA利用率/临床数据以及Medicare索赔联系起来，以检查激烈与去强化治疗中CLC的变化；确定导致这种差异的患者，护理人员，提供者和设施因素；并确定对全因和疾病特异性负面事件的影响。我们的分析方法涉及具有治疗权重的逆概率的承诺得分方法，以解决潜在的选择偏见和混淆。利用AIM 1的结果来通常从具有较低比例的受主动治疗居民（LLE/AD建议的“早期采用者”）和较高比例的自然处理居民（“后期采用者”）的CLC取样，定性目标3将涉及半结构化的访谈与最近已故CLC居民的提供者和家庭护理者的半结构访谈。通过合作伙伴的意见，我们将使用这些数据来绘制关键障碍和促进者来实施LLE/AD特定建议，并开发一种干预工具包，该工具包将作为QI努力的基础。这项研究涉及有关VA蓝图的长期护理和护理和策略的HSR＆D优先领域。通过为VA提供优化QI努力以促进LLE/AD特定治疗建议的实施所需的关键信息和工具，这将产生重大影响，并支持改善有关CLC居民在寿命末期的CLC居民的共同决策。