Optimizing Specialty Care Access for Veterans with End-Stage Organ Diseases

优化患有终末期器官疾病的退伍军人的特殊护理机会

• 批准号: 10746990
• 负责人: Megan Adkins Adams
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-10-01 至 2027-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10746990
• 关键词: Address; Affect; Attitude; Automobile Driving; Black race; Caring; Chronic Disease; Chronic Kidney Failure; Cirrhosis; Clinic; Clinical; Clinical Management; Complex; Data; Development; Disease; Disease Management; Eligibility Determination; Enrollment; Ensure; Equity; Ethnic Origin; Evaluation; Female; Gastroenterologist; Gastroenterology; Gender; Goals; Grant; Health Services Accessibility; Health system; High Prevalence; Inequity; Inpatients; Interview; Investigation; Kidney; Kidney Diseases; Knowledge; Leadership; Life; Liver; Liver diseases; Methods; Mission; Nephrology; Organ; Outcome; Outpatients; Pathway interactions; Patients; Perception; Policies; Predisposition; Process; Provider; Quality of Care; Recommendation; Research; Resources; Role; Sampling; Severity of illness; Specialist; Structure; Surveys; System; Telephone; Transplantation; Variant; Veterans; Veterans Health Administration; Waiting Lists; Work; care delivery; care fragmentation; care providers; chronic liver disease; cohort; community setting; design; end stage liver disease; high risk; improved; innovation; medical specialties; multidisciplinary; multilevel analysis; observational cohort study; parity; post-transplant; primary care provider; provider factors; social health determinants; system-level barriers; virtual

Background: Low rates of referral to specialty care among Veterans represent a significant barrier to access and optimal clinical outcomes. This is particularly true for Veterans with end-stage organ diseases (e.g., advanced chronic kidney disease (CKD), decompensated cirrhosis), who are potentially eligible for life-saving transplantation and require specialty care for optimal disease management. Despite the high prevalence of end-stage liver and kidney diseases among Veterans, less than a third of Veterans with advanced CKD and decompensated cirrhosis are referred to a specialist and <5% for transplant evaluation. A comprehensive assessment of patient-, provider- and system-level factors influencing specialty care referral and referral for transplant evaluation is critical to developing targeted strategies and approaches to optimize referral appropriateness as there is a clear association between being seen by a specialist and improved survival. Significance/Impact: Ensuring timely access to high-quality primary and specialty care is a core mission of the Veterans Health Administration (VHA). Factors affecting specialty care referral and referral for transplant evaluation among Veterans with advanced chronic liver and kidney diseases are incompletely characterized. This knowledge is critical to designing effective strategies to enhance referral appropriateness and optimize access. Hence, there is an urgent unmet need to improve our understanding of these complex relationships and the mechanisms by which they affect referral to specialty care and referral for transplant evaluation. Innovation: Most existing work has focused on steps downstream of referral to specialty care and for transplant evaluation, such as completion of transplant evaluation, waitlisting, transplant receipt, and post- transplant outcomes -- thus, barriers to specialty care referral and referral for transplant evaluation remain understudied. This study will comprehensively examine and identify the multi-level factors driving referral to specialty care and referral for transplant evaluation, with the goal of generating best practice recommendations to optimize referral appropriateness and equity. This knowledge is critical to improving referral processes/pathways, enhancing Veteran outcomes, and informing policy changes to increase parity in access. Aims: 1) Characterize the multi-level factors associated with specialty referral and referral for transplant evaluation among patients with advanced chronic liver and kidney diseases. 2) Examine patient and provider knowledge, attitudes, and perceived barriers/facilitators of specialty care referral and referral for transplant evaluation. 3) Develop best practice recommendations to optimize referral appropriateness and equity using modified Delphi panels. Project Methods: Aim 1 is a retrospective observational cohort study using multi-level modeling to identify key patient-, provider-, and system-level factors associated with non-referral to specialty care and for transplant evaluation. As part of Aim 1, the impact of social determinants of health on referral to specialty care and for transplant evaluation also will be evaluated. In Aim 2, we will conduct semi-structured qualitative interviews with primary and specialty care providers and patients sampled from 6 VA health systems to explore variation in knowledge, attitudes, and perceived barriers/facilitators of referral to specialty care and for transplant evaluation. In Aim 3, we will use a modified Delphi approach to convene two panels of VA operational leaders and other experts to develop best practice recommendations to maximize referral appropriateness and equity. Implementation/Next Steps: This study will provide critical information regarding key factors impacting specialty care referral and referral for transplant evaluation among vulnerable Veterans with advanced chronic liver and kidney diseases. Products of the grant will provide vital information to VHA leaders on how to enhance referral appropriateness and equity by generating actionable strategies to address key barriers to referral to specialty care and for transplant evaluation.

背景：退伍军人之间的低转诊率转介到专业护理的速度 和最佳临床结果。对于患有终阶段器官疾病的退伍军人尤其如此（例如， 晚期慢性肾脏疾病（CKD），肝硬化的代偿性疾病），他们有资格挽救生命 移植并需要专业护理才能进行最佳疾病管理。尽管患病率很高 退伍军人中的末期肝脏和肾脏疾病，不到有高级CKD的退伍军人和 肝硬化是专家的，<5％用于移植评估。全面 评估患者，提供者和系统级别的因素影响专业护理转诊和转诊 移植评估对于制定有针对性的策略和方法以优化推荐至关重要 适当性是因为专家看到和改善生存之间存在明显的关联。 意义/影响力：确保及时获得高质量的初级和专业护理是一个核心使命 退伍军人卫生管理局（VHA）。影响专业护理转介和移植转诊的因素 患有晚期慢性肝脏和肾脏疾病的退伍军人的评估未完全表征。 这些知识对于设计有效的策略至关重要，以增强推荐适当性和优化 使用权。因此，紧急未满足需要提高我们对这些复杂关系的理解 以及它们影响转介到专业护理和转诊的移植评估的机制。 创新：大多数现有的工作都集中在转介到专业护理和专业的步骤上 移植评估，例如完成移植评估，等待列表，移植收据和后 移植结果 - 因此，专业护理转介的障碍和移植评估的转诊障碍仍然存在 研究了。这项研究将全面检查并确定推荐转介到的多层次因素 专业护理和转诊用于移植评估，目的是产生最佳实践建议 优化推荐适用性和公平性。这些知识对于改善推荐至关重要 流程/途径，增强退伍军人成果并告知政策变化以提高访问权限的均等。 目的：1）特征与专业转介和移植转介相关的多层次因素 晚期慢性肝脏和肾脏疾病患者的评估。 2）检查患者和提供者 专业护理转诊和移植推荐的知识，态度和感知的障碍/促进者 评估。 3）开发最佳实践建议，以优化推荐适当性和权益 修改后的Delphi面板。 项目方法：AIM 1是一项回顾性观察队列研究，使用多层建模来识别钥匙 患者 - 提供者，提供者和系统级别因素与专业护理和移植有关 评估。作为目标1的一部分，健康决定因素对转介专业护理的影响以及 还将评估移植评估。在AIM 2中，我们将进行半结构化定性访谈 从6个VA卫生系统中取样的初级和专业护理提供者和患者探索变化 在知识，态度和感知的障碍/促进者转介到专业护理和移植 评估。在AIM 3中，我们将使用修改后的Delphi方法来召集两个VA运营领导者面板 以及其他专家开发最佳实践建议，以最大程度地提高推荐适当性和公平性。 实施/下一步：本研究将提供有关影响关键因素的关键信息 专业护理转介和转诊，用于在具有高级慢性的弱势退伍军人之间进行移植评估 肝脏和肾脏疾病。赠款的产品将向VHA领导人提供有关如何的重要信息 通过产生可行的策略来解决关键障碍，以提高推荐适当性和公平性 转介到专业护理和移植评估。