Improving Implementation of Outpatient Goals of Care Conversations for Veteranswith Serious Illness

改善患有严重疾病的退伍军人护理对话门诊目标的实施

• 批准号: 10188883
• 负责人: David B. Bekelman
• 金额: --
• 依托单位: VA EASTERN COLORADO HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-10-01 至 2025-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10188883
• 关键词: Academy; Address; Breathing; COVID-19; COVID-19 morbidity; COVID-19 mortality; Cardiopulmonary Resuscitation; Caregivers; Caring; Cessation of life; Characteristics; Chronic; Chronic Obstructive Airway Disease; Collaborations; Colorado; Data; Dementia; Documentation; Effectiveness; Ensure; Ethics; Evaluation; Failure; Family; Fostering; Foundations; Goals; Health; Health Personnel; Health system; Healthcare; Healthcare Systems; Heart failure; Hospitalization; Inpatients; Interview; Kidney Diseases; Learning; Life; Liver diseases; Los Angeles; Lung diseases; Malignant Neoplasms; Mechanical ventilation; Medical; Medical center; Medicine; Methodological Studies; Methods; Needs Assessment; Outpatients; Palliative Care; Participant; Patients; Personal Satisfaction; Persons; Policies; Primary Health Care; Provider; Randomized; Research; Research Design; Resources; Resuscitation; Risk; Sequential Multiple Assignment Randomized Trial; Site; Surveys; Testing; Time; Training; Veterans; Visit; base; data warehouse; decision-making capacity; effectiveness evaluation; end of life care; evidence base; experience; falls; high risk; implementation strategy; implementation study; improved; innovation; interest; meetings; member; nutrition; operation; population based; preference; prognostic; research and development; success; telehealth; trial comparing; web site

Background: VA implemented the Life Sustaining Treatment Decisions Initiative (LSTDI) to elicit, document, and honor the values, goals, and preferences of Veterans with serious illness. The National Academy of Medicine recommends, and patients and families prefer goals of care conversations (the foundation of the LSTDI) occur when they are not acutely ill in the outpatient setting. However, across VA nationally, most goals of care conversations occur in the inpatient setting close to death; only 39% occur in the outpatient setting. Significance/Impact: This study will identify strategies to improve LSTDI implementation in the outpatient setting. This is significant to Veterans because it ensures they can express their goals and preferences for life sustaining treatments and have them honored. Two VA Secretary priorities are addressed: (1) the goal to provide “clear information to make informed decisions” about life-sustaining treatments, and (2) the goal for Veterans to receive “care and support… that emphasizes their well-being and independence throughout their life journey.” This proposal addresses the R&D goal to increase real-world impact of VA research by understanding how to improve implementation of a national VA policy. Alignment with HSR&D priorities is described in the proposal. Innovation: The proposal uses an innovative study design, a sequential multiple assignment randomized trial (SMART). The combination of patient-facing and provider-facing implementation strategies, deemed important in our preliminary studies, is also innovative. Finally, we take a population-based approach to understand the implementation of goals of care conversations in seriously ill Veterans with serious non-cancer illnesses including heart failure and chronic pulmonary, renal, and kidney diseases. Specific Aims. Aim 1. Use a clinician-level SMART in three VA health systems to determine the effectiveness of clinician and patient implementation strategies to improve the occurrence of documented goals of care conversations in Veterans with serious medical illness. Aim 2a. Identify the sequence of implementation strategies that leads to the overall greatest increase in documentation of goals of care conversations. Aim 2b (exploratory). Identify patient and clinician characteristics that modify the effect of sequences of implementation strategies on documentation of goals of care conversations. Aim 3. Understand clinician and patient implementation strategy success or failure using a mixed method evaluation involving clinicians, leaders, patients, and caregivers. Methodology: Study sites include the VA Eastern Colorado, Greater Los Angeles, and Palo Alto Health Care Systems. We will target clinicians with low rates of goals of care conversations among Veterans with medical illness in the top 10th percentile of risk of hospitalization or death. We will first test less resource intensive strategies, and subsequently randomize PACT teams with continued low rates of conversations to either an increased intensity of the current strategy or more time with the current strategy. Data will be collected from the VA Corporate Data Warehouse (Aims 1 and 2) and patient, caregiver, and clinician interviews or surveys (Aims 2 and 3). Data will be analyzed using qualitative and quantitative methods. Next Steps/Implementation: Study findings will be disseminated in collaboration with our operations partners (National Center for Ethics in Health Care, Primary Care, Palliative Care). Our partners can implement policies based on study findings to increase early, outpatient implementation of the LSTDI.

背景：VA实施了维持生命的治疗决策计划（LSTDI），以引发，文件， 并尊重患有严重疾病的退伍军人的价值观，目标和偏好。国家学院 医学建议，患者和家庭更喜欢护理对话的目标（ 当LSTDI）在门诊环境中不急切时会发生。但是，在全国范围内，大多数目标 在接近死亡的住院环境中发生了护理对话；门诊环境中只有39％发生。 意义/影响：本研究将确定改善门诊中LSTDI实施的策略 环境。这对退伍军人很重要，因为它可以确保他们可以表达自己的目标和偏好 维持治疗并让他们荣幸。解决了两个VA秘书优先事项：（1） 提供有关维持生命治疗的“明确信息以做出明智的决定”，以及（2） 退伍军人接受“关怀和支持……这强调了他们的福祉和独立性 生命之旅。 了解如何改善国家VA政策的实施。与HSR＆D的优先级保持一致是 在提案中描述。 创新：该提案使用创新研究设计，这是一个顺序多次分配随机试验 （聪明的）。面向患者和面向提供者的实施策略的结合被认为很重要 在我们的初步研究中，也是创新的。最后，我们采用基于人群的方法来了解 实施患有严重非癌症的严重患病退伍军人的护理对话目标 包括心力衰竭和慢性肺部，肾脏和肾脏疾病。 具体目标。目标1。在三个VA卫生系统中使用临床水平智能来确定有效性 临床和患者实施策略以改善已记录的护理目标的发生 患有严重医学疾病的退伍军人对话。目标2a。确定实施的顺序 导致护理对话目标文档的总体增长最大的策略。目标2B （探索性）。确定改变实施序列影响的患者和临床特征 有关护理对话目标记录的策略。目标3。了解临床和患者 实施策略成功或使用涉及临床医生，领导者， 病人和看护人。 方法论：研究站点包括VA东科罗拉多州，大洛杉矶和帕洛阿尔托医疗保健 系统。我们将针对退伍军人与医疗的退伍军人的护理对话目标率低的临床医生 疾病是住院或死亡风险的十大百分点。我们将首先测试资源密集程度较少 策略，随后将持续较低对话率的协议团队随机分配给 当前策略的强度增加了当前策略的强度。数据将从 VA公司数据仓库（目标1和2）以及患者，护理人员和临床访谈或调查 （目标2和3）。数据将使用定性和定量方法分析。 下一步/实施：研究结果将与我们的运营合作伙伴合作传播 （国家医疗保健伦理学中心，初级保健，姑息治疗）。我们的合作伙伴可以实施政策 基于研究结果，以提早增加LSTDI的门诊实施。