Impact of COVID-era Disrupted Care on Disparities in Outcomes among Veterans with Kidney Failure

新冠病毒时代护理中断对肾功能衰竭退伍军人结果差异的影响

• 批准号: 10755601
• 负责人: AMAL N. TRIVEDI
• 金额: --
• 依托单位: DURHAM VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-08-01 至 2024-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10755601
• 关键词: Acute; Address; Affect; Ambulatory Care; Area; Authorization documentation; Blood Vessels; COVID-19; COVID-19 impact; COVID-19 morbidity; COVID-19 pandemic; COVID-19 vaccination; Caring; Chronic; Clinic; Clinical; Collaborations; Communities; Community Financing; Community Healthcare; Comparative Study; Complex; Computerized Medical Record; Critical Care; Data; Dedications; Diagnostic; Dialysis patients; Dialysis procedure; Disasters; Disease Management; Disparity; Economically Deprived Population; Emergency Situation; End stage renal failure; Enrollment; Evaluation; Frequencies; Future; Health; Health Personnel; Health Services Accessibility; Health Services Administration; Healthcare; Immunocompromised Host; Improve Access; Integrated Health Care Systems; Intervention; Kidney; Kidney Diseases; Kidney Failure; Life; Longitudinal cohort study; Maintenance; Managed Care; Medicare; Methodology; Morbidity - disease rate; Nature; Neighborhoods; Outcome; Patient Transfer; Patients; Patterns of Care; Phase; Policies; Predisposition; Primary Care; Private Sector; Procedures; Process; Provider; Public Health; Recovery; Renal function; Research; Resources; Risk Factors; SARS-CoV-2 exposure; SARS-CoV-2 infection; Services; Shapes; Social Work; Socioeconomic Status; Structure; Survival Rate; System; Time; Vaccines; Veterans; Veterans Health Administration; Work; access disparities; authority; care delivery; care fragmentation; care providers; care systems; cohort; community setting; coronavirus disease; ethnic disparity; ethnic minority; experience; health equity; improved; medical specialties; military veteran; mortality; multiple chronic conditions; outcome disparities; pandemic disease; pandemic impact; participant enrollment; patient population; programs; racial disparity; racial minority; social; social health determinants; socioeconomic disadvantage; socioeconomic disparity; tertiary care; treatment adherence

Background: The COVID-19 pandemic significantly disrupted care delivery that limited access to providers, acute and timely non-acute evaluation, and clinical intervention. Dialysis patients with kidney failure are particularly vulnerable to COVID-19 infection, COVID-19 related morbidity and mortality because they commonly have multiple chronic conditions, typically require thrice weekly life-sustaining dialysis treatment in close- quartered clinic settings, are already prone to fragmented care, and especially susceptible to disrupted care. The COVID-19 pandemic presents fundamental threats to dialysis patients, and there is an urgent need to examine the impact of disrupted care for this vulnerable and uniquely healthcare reliant population of patients. Over 16,000 of enrolled Veterans receive chronic dialysis through Veterans Health Administration (VA) Kidney Program’s VA and VA Community Care providers. VA Community Care improves access to life- sustaining dialysis services for 80% of Veterans with kidney failure with limited access to the VHA’s 70 dialysis units. In prior work, we found lower 2-year mortality among Veterans receiving dialysis exclusively in VA compared to those receiving dialysis in non-VA settings, consistent with VA and non-VA comparative studies in other clinical contexts. These differences may be due to more comprehensive integrated services (e.g., co- located primary and tertiary care services, care management, social work, national electronic medical record) in VA, compared with the more fragmented and siloed dialysis care in private sector community settings. Significance: Pandemic-related disruptions may disproportionately affect Veterans with serious conditions and social risk factors like those with kidney failure and the nature and impact of pandemic-related disruptions may differ in VA and non-VA systems. However, rigorous comparisons of COVID-related care disruptions and outcomes between Veterans receiving healthcare in VA and non-VA settings are lacking. Specific Aims: Building on our team’s research expertise, this study will: 1) Quantify the impact of COVID-19 on 1a) disrupted care for prevalent patients and 1b) deferred care for incident patients in a national cohort of Veterans with ESKD and compare the extent of these impacts between VA- financed dialysis care in VA and VA Community Care settings from 2018-2022. 2) Compare patient-level outcomes and racial and socioeconomic disparities in outcomes in VA and non-VA dialysis settings before and during the COVID pandemic time periods. Methodology: We will conduct a longitudinal cohort study of all VA-enrolled patients with end-stage kidney disease receiving VA-financed dialysis care between 2018 and 2022, to observe care patterns before the pre- COVID phase (Jan 2018-Feb 2020), the acute COVID phase defined as the first case of COVID until authorization of the vaccine (Mar 2020-Dec 2020) and the recovery phase when COVID-19 vaccination was available (Jan 2021-Dec 2022). Study data will be derived from linkages of VA and Medicare administrative data with community-level national COVID-19 tracking and neighborhood socioeconomic status data to assess the impacts of pandemic-related disruptions in care on disparities in outcomes among Veterans receiving dialysis in VA and non-VA settings. Next Steps/Implementation: This research is directly responsive to the COVID RFA HX-21-025: Pandemic related disrupted and deferred care and three VA HSR&D priority areas (Access to Care, Complex Disease Management, Social Determinants of Health). The study team is conducting this work partnership with the VHA National Program for Kidney Disease to ensure that our work is poised to shape evolving VA policy around provision of community care and to improve care for Veterans during the COVID-19 pandemic, recovery, and future public health crises. Results will inform how VA manages its Veterans in disaster scenarios, particularly with provider partners in VA community care, for whom the VA relies on for reliable and accessible dialysis care.

背景：COVID-19 大流行严重扰乱了护理服务的提供，限制了提供者的获取， 急性和非急性肾功能衰竭患者的及时评估和临床干预。 特别容易受到 COVID-19 感染、COVID-19 相关发病率和死亡率的影响，因为他们通常 患有多种慢性病，通常需要每周三次在近距离进行维持生命的透析治疗 诊所环境本来就很分散，而且特别容易受到护理中断的影响。 COVID-19 大流行对透析患者构成根本威胁，迫切需要进行检查 护理中断对这一脆弱且独特的医疗依赖患者群体的影响。 超过 16,000 名登记退伍军人通过退伍军人健康管理局 (VA) 接受慢性透析 肾脏计划的 VA 和 VA 社区护理提供者改善了生活的可及性。 为 80% 患有肾衰竭的退伍军人提供维持透析服务，但获得 VHA 的 70 名透析机会有限 在之前的工作中，我们发现仅在退伍军人管理局接受透析的退伍军人的 2 年死亡率较低。 与在非 VA 环境中接受透析的患者相比，与 VA 和非 VA 比较研究一致 这些差异可能是由于更全面的综合服务（例如，共同服务）造成的。 位于初级和三级护理服务、护理管理、社会工作、国家电子病历） VA 与私营部门社区环境中更加分散和孤立的透析护理相比。 意义：与大流行相关的干扰可能会对患有严重疾病的退伍军人和 肾衰竭等社会风险因素以及与流行病相关的破坏的性质和影响可能会 然而，退伍军人事务部和非退伍军人事务部系统的情况有所不同。 退伍军人事务部和非退伍军人事务部接受机构的退伍军人医疗保健之间的结果缺乏。 具体目标：基于我们团队的研究专业知识，本研究将： 1) 量化 COVID-19 对 1a) 对流行患者的护理中断和 1b) 对事件的延期护理的影响 国家退伍军人队列中患有 ESKD 的患者，并比较 VA- 从 2018 年至 2022 年资助 VA 和 VA 社区护理机构的透析护理。 2) 比较 VA 和非 VA 患者的结局以及种族和社会经济差异 新冠肺炎大流行之前和期间的透析设置。 方法：我们将对 VA 招募的所有终末期肾病患者进行纵向队列研究 2018 年至 2022 年间接受 VA 资助的透析护理的疾病，以观察治疗前的护理模式 新冠肺炎阶段（2018 年 1 月至 2020 年 2 月），急性新冠肺炎阶段定义为第一例新冠肺炎病例，直至 疫苗的授权（2020 年 3 月至 2020 年 12 月）以及 COVID-19 疫苗接种的恢复阶段 可用（2021 年 1 月至 2022 年 12 月）研究数据将来自 VA 和 Medicare 管理数据的关联。 利用社区级国家 COVID-19 跟踪和社区社会经济状况数据来评估 与大流行相关的护理中断对接受透析的退伍军人结果差异的影响 VA 和非 VA 设置。 后续步骤/实施：本研究直接响应 COVID RFA HX-21-025：流行病 相关的中断和延期护理以及 VA HSR&D 的三个优先领域（获得护理、复杂疾病 管理、健康的社会决定因素）研究小组正在与 VHA 开展这项工作合作。 国家肾脏疾病计划，确保我们的工作能够围绕制定不断发展的 VA 政策 提供社区护理并改善在 COVID-19 大流行期间、康复期间对退伍军人的护理 未来的公共卫生危机结果将告诉退伍军人管理局如何在灾难情况下管理退伍军人。 与 VA 社区护理的提供者合作伙伴合作，VA 依靠他们提供可靠且方便的透析护理。