De-Intensifying Unnecessary Medications in VA CLC Residents Nearing 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与其护理目标相一致的药物，提高向预期寿命有限(LLE)和/或晚期痴呆症(AD)的VA社区生活中心(CLC)居民提供的护理质量。在……里面 在阿尔茨海默病和其他限制生命的疾病发展之前的几年里，大多数CLC居民积累了需要药物治疗的多种慢性病(例如冠状动脉疾病、高血压、糖尿病)。然而，为普通成年人制定的呼吁强化治疗这些疾病的实践指南可能不再适合患有LLE/AD的居民，因为患者的生存潜力降低，足以体验到好处，并有更高的药物不良反应倾向。几个老年组已经发布了针对LLE/AD患者避免进行高强度慢性病治疗的建议，但这些建议并未一致地纳入VA或其他疾病特定指南，它们在CLC实践中的采用尚不清楚。这些针对LLE/AD患者的建议也主要是基于专家对假设的风险和益处的共识，而不是关于LLE/AD患者严格设计的研究的实际风险和收益的直接证据。缺乏关于这种风险/利益平衡的直接和具体证据，阻碍了退伍军人、他们的非正式照顾者和退伍军人管理局提供者做出与退伍军人护理目标一致的知情、共同决定的能力。我们与退伍军人事务部老年和延长护理服务办公室(GEC)、退伍军人管理局承诺中心(绩效报告和结果测量以改善临终关怀标准)、退伍军人药房福利管理(PBM)和CLC临床医生合作，提出了一项混合方法研究，以了解进入CLC的退伍军人强化和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)工作的基础。具体目标是(1)描述入院后患有LLE/AD的退伍军人接受强化和非强化治疗的血脂、血压和血糖控制的模式；(2)检查入院后接受强化治疗的LLE/AD患者的血脂、血压和血糖控制对所有原因负面事件以及患有LLE/AD的退伍军人住院和急诊的影响；以及(3)利用对提供者和家庭照顾者的半结构化访谈和建立的干预地图框架，确定实施LLE/AD特定建议的关键障碍和促进者，并设计干预工具包，作为QI工作的基础。对于量化目标1-2，我们将连接最小数据集(MDS)评估、PBM用药记录、VA利用/临床数据和Medicare声明，以检查强化和非强化治疗中CLC的差异；确定导致这种差异的患者、护理者、提供者和设施因素；并确定对所有原因和特定疾病的负面事件的影响。我们的分析方法包括倾向性计分方法和处理权重的反向概率，以解决潜在的选择偏差和混杂。利用目标1的结果，有目的地从接受密集治疗的居民比例较低(接受LLE/AD建议的“早期采用者”)和接受密集治疗的居民比例较高(“后期采用者”)的社区卫生服务中心中抽取样本，定性目标3将涉及对最近去世的社区卫生服务中心居民的提供者和家庭照顾者的半结构化访谈。在我们合作伙伴的投入下，我们将利用这些数据绘制出实施LLE/AD特定建议的关键障碍和促进者，并开发一个干预工具包，作为QI工作的基础。这项研究涉及长期护理和护理的高铁和研发优先领域，以及退伍军人管理局卓越蓝图的战略1-3。它将产生重大影响，为退伍军人管理局提供优化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，并支持改善CLC临终居民关于药物治疗的共享决策。

 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.