Alignment of Treatment Preferences and Repair Type for Veterans with AAA

每年有近5,000名退伍军人在VA医院接受腹主动脉瘤（AAA）修复术。 随机试验，包括基于VA的开放与血管内修复（OVER）试验，发现 腹主动脉瘤腔内修复术（EVAR）与围手术期发病率和死亡率较低、疼痛较轻相关， 住院时间比开放手术修复（OSR）短。然而，OSR更耐用， 晚期破裂等并发症，接受腹主动脉瘤腔内修复术和OSR治疗的退伍军人在两个月内的生存率相似 手术后几年。考虑到这些权衡，关于哪种方法最适合于 AAA修复的个体退伍军人和初步分析需要发现VA之间存在广泛的差异 医院如何对待退伍军人AAA。AAA的治疗决定需要与退伍军人的 喜好例如，一个退伍军人，对他来说，快速恢复是最重要的， 耐久性问题较少，治疗偏好与腹主动脉瘤腔内修复术最接近。类似地第 希望避免重复随访和延迟再干预的退伍军人有一种治疗偏好， 与OSR最接近。然而，尽管VA医院的AAA治疗类型各不相同，但尚不清楚是否 这些治疗变化是退伍军人偏好的结果，或者独立于退伍军人的偏好。 喜好外科医生对修复类型的偏好描述不足，特别是对于外科医生治疗 老兵 在初步工作中，我们进行了观察分析，调查和认知访谈。这工程 已证明VA中AAA修复类型的变化，并改进了定性方法，以更好地了解 退伍军人和外科医生的治疗决定。在这项提案中，在一群退伍军人谁是候选人， 无论是哪种修复类型（OSR或腹主动脉瘤腔内修复术），我们都将通过调查探索退伍军人对AAA的知识和偏好 修复，并确定是否退伍军人谁收到决策援助以及调查更有可能收到 他们的治疗选择 我们描述了一项群集随机试验，比较了两种更好地调整退伍军人偏好的方法， AAA的治疗：（1）描述AAA修复类型的经验证的决策辅助工具， 偏好修复类型--对比（2）单独的调查。登记的退伍军人将是候选人， 血管内或开放修复，并在VA医院由血管外科团队定期进行 两种修复方式。在目标1中，我们将确定退伍军人对腔内或开放修复术的偏好， 标识与每种修复类型相关联的域。在目标2中，我们将比较退伍军人 偏好和修复类型之间的决策援助+调查和调查组。我们将确定因素 与协议有关。我们的研究结果将报告给国家外科办公室血管外科 咨询委员会，以帮助确保退伍军人的喜好仍然是AAA治疗决定的中心。我们 我已经招募了20个退伍军人医疗中心和他们的血管外科团队，他们渴望参与这项工作。 帮助退伍军人做出最好的决定。

Nearly 5,000 Veterans undergo abdominal aortic aneurysm (AAA) repair each year in VA hospitals. Randomized trials, including the VA-based Open Versus Endovascular Repair (OVER) Trial, have found endovascular AAA repair (EVAR), is associated with lower perioperative morbidity and mortality, less pain, and shorter length of stay than open surgical repair (OSR) However, OSR is more durable, has fewer long-term complications such as late rupture, and Veterans treated with EVAR and OSR have similar survival within two years following surgery. Given these tradeoffs, controversy remains as to which method is best suited for an individual Veteran who AAA repair, and preliminary analyses needs have found broad variations across VA hospitals in how Veterans are treated for AAA. Treatment decisions for AAA need to be aligned with Veterans' preferences. For example, a Veteran for whom a rapid recovery is of primary importance and long-term durability a lesser concern has a treatment preference which aligns most closely with EVAR. Similarly, a Veteran who wishes to avoid repeated follow-up visits and late re-interventions has a treatment preference that aligns most closely with OSR. However, while AAA treatment type varies across VA hospitals, it is unknown if these treatment variations occurs as a result of Veterans preferences, or independent of Veterans' preferences. Surgeon preferences for repair type have been poorly described, especially for surgeons treating Veterans. In preliminary work, we have performed observational analyses, surveys, and cognitive interviews. This works has demonstrated variation in AAA repair type in VA and refined qualitative methods to better understand Veterans' and surgeons’ treatment decisions. In this proposal, in a cohort of Veterans who are candidates for either repair type (OSR or EVAR), we will use a survey explore Veterans' knowledge and preferences for AAA repair, and determine if Veterans who receive a decision aid as well as the survey are more likely to receive their treatment choice. We describe a cluster-randomized trial comparing two ways to better align Veterans' preferences and treatments for AAA: (1) a validated decision aid describing AAA repair types with a survey measuring Veterans' preference for repair type -- versus (2) the survey alone. Enrolled Veterans will be candidates for either endovascular or open repair, and be followed at VA hospitals by vascular surgery teams who regularly perform both types of repair. In Aim 1, we will determine Veterans' preferences for endovascular or open repair and identify domains associated with each repair type. In Aim 2, we will compare agreement between Veterans' preferences and repair type between the decision aid+survey and survey-alone groups. We will identify factors associated with agreement. Our findings will be reported to the National Surgery Office Vascular Surgery Advisory Board to help ensure Veterans' preferences remain at the center of AAA treatment decisions. We have recruited 20 VA Medical Centers and their vascular surgery teams who are anxious to participate in this important trial to help Veterans make the best decisions.