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: 9768203
• 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 2020-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9768203
• 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; improved; informal caregiver; insight; 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药物来提高为 VA 社区生活中心 (CLC) 预期寿命有限 (LLE) 和/或晚期痴呆 (AD) 居民提供的护理质量与他们的护理目标一致。 在出现 AD 和其他限制生命的冠状动脉疾病之前的几年中，大多数 CLC 居民已经积累了多种需要药物治疗的慢性疾病（例如动脉疾病、高血压、糖尿病）。对于患有 LLE/AD 的居民来说，对这些疾病的强化治疗可能不再适合，因为他们的寿命缩短，无法获得获益，而且一些老年群体更容易出现药物不良反应，因此建议患者避免进行强化慢性病治疗。与 LLE/AD，但是这些建议尚未一致地纳入 VA 或其他特定疾病指南，并且它们在 CLC 实践中的采用情况尚不清楚。这些 LLE/AD 特定建议也很大程度上基于专家对所利用风险和益处的共识，而不是有关实际的直接证据。对 LLE/AD 患者进行严格设计的研究的风险和益处缺乏关于这种风险/收益平衡的直接和具体证据，阻碍了退伍军人、他们的非正式护理人员和 VA 提供者做出与退伍军人一致的知情、共同决策的能力。 ' 在伙伴关系中的目标。与 VA 老年和延伸护理服务办公室 (GEC)、VA PROMISE 中心（旨在提高临终护理标准的绩效报告和结果衡量）、VA 药房福利管理 (PBM) 和 CLC saints 合作，我们提出一项混合方法研究，以了解接受 CLC 的退伍军人的强化治疗与非强化治疗的差异和结果，并开发干预工具包作为质量改进 (QI) 的基础具体工作是 (1) 描述 CLC 入院后患有 LLE/AD 的退伍军人接受强化治疗与非强化治疗的血脂、血压 (BP) 和血糖控制模式；(2) 检查强化治疗对血脂、血压 (BP) 和血糖控制的影响； CLC 入院后对患有 LLE/AD 的退伍军人的全因负面事件和特定疾病住院治疗和紧急就诊的血脂、血压和血糖控制；(3) 使用与提供者和家庭护理人员的半结构化访谈以及既定的干预图谱框架，确定实施 LLE/AD 具体建议的主要障碍和促进因素，并设计一个干预工具包作为定量 QI 工作的基础。对于目标 1-2，我们将链接最小数据集 (MDS) 评估、PBM 用药记录、VA 利用。 /临床数据，医疗保险声称检查 CLC 在强化治疗和非强化治疗中的差异；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采用治疗权重逆概率的倾向评分方法，以解决潜在的选择偏差和混杂问题，使用目标 1 的结果有目的地从接受强化治疗的居民（LLE/AD 建议的“早期采用者”）比例较低的 CLC 中进行抽样。由于接受严格治疗的居民（“晚期收养者”）比例较高，定性目标 3 将涉及对最近去世的 CLC 居民的提供者和家庭护理人员进行半结构化访谈。根据我们合作伙伴的意见，我们将使用。这些数据可绘制实施 LLE/AD 具体建议的主要障碍和促进因素，并开发一个干预工具包，作为 QI 工作的基础。本研究涉及长期护理和护理以及策略 1-3 的 HSR&D 优先领域。 VA 卓越蓝图将为 VA 提供优化 QI 工作所需的关键信息和工具，以促进 LLE/AD 特定治疗建议的实施，并支持改进附近 CLC 居民的药物共享决策，从而产生重大影响。生命终结。