Defining Optimal Care for Urinary Stone Disease in the Veterans Health Administration

背景：尿石症给人类带来了巨大的经济和健康负担。 美国和退伍军人健康管理局(VHA)。当前交付的障碍 对美元患者的最佳医疗保健包括缺乏循证流程措施 和治疗以及二级预防措施的复杂性。 意义/影响：目前关于美元最佳做法管理的指导方针主要是 基于临床原则或专家意见。相对缺乏循证指导方针 可能导致次优护理并导致护理质量的不受欢迎的实践模式变异性 美元。拟议的研究将涉及以下VHA/ORD优先事项：初级保健 复杂慢性病(如复发性美元)和质量的实践和管理 预防美元的措施。 创新：拟议的研究将决定哪些指导方针建议的战略 对美元的二级预防有效。随机临床试验还没有开始 因此，我们的发现有望迅速扩大证据基础 优化美元的护理，将美元的临床实践范式转向初级保健 让更多患有美元的退伍军人能够得到有效的结石预防。 具体目标：我们提出以下具体目标：1)确定哪些预防措施 措施与VHA中较低的美元复发率相关；2)评估VHA如何 供应商目前正在为美元实施预防措施；以及3)确定当前 在VHA实施有效的美元预防措施的障碍。我们假设 1)预防措施，如筛查原发性甲状旁腺功能亢进症，24- 小时尿检和开结石相关药物的处方与较长的时间有关 复发美元和/或结石事件较少的时间段；2)初级保健提供者较少 比专业提供商更有可能为美元实施预防措施；以及3)每一家提供商 类型面临独特的障碍，减少了有效的结石预防措施的利用。 方法：目标1将确定发生或复发的美国退伍军人的全国队列 并使用模拟随机临床试验的方法来确定哪些 指南-建议的措施导致第二次美元事件的时间更长或美元更少 事件。目标2将检查接受初级保健的患者的比例， 肾病学和泌尿科提供商跟踪他们的索引结石事件并确定哪些 提供者或多或少有可能实施每一项预防措施。目标3将进行 对VHA附属的初级保健、肾病和泌尿外科提供者进行的全国性调查 找出实施有效的结石预防措施的障碍。 后续步骤/实施：VHA处于支持比较优势的理想位置 有效性研究，以确定哪些最佳实践指南在减少 美元重现。拟议的研究将更清楚地界定以下最佳做法管理 评估VHA提供者目前实施预防措施的情况，以及 找出阻碍市政总署统一采用最佳做法管理的障碍 VHA。我们预计，我们的发现将为未来临床试验的设计提供参考(在哪里 可行)，并促进市政总署的最佳护理实践在VHA内外的传播。

Background: Urinary stone disease (USD) imposes a major economic and health burden on the United States and the Veterans Health Administration (VHA). Current barriers to delivering optimal health care to patients with USD include the dearth of evidence-based process measures and treatments and the complexity of secondary prevention measures for USD. Significance/Impact: Current guidelines for best practice management of USD are largely based on clinical principles or expert opinion. The relative lack of evidence-based guidelines may lead to suboptimal care and drive unwanted practice pattern variability of quality of care for USD. The proposed research will address the following VHA/ORD priorities: Primary care practice and management of complex chronic diseases (such as recurrent USD) and quality measurement of USD prevention. Innovation: The proposed research will determine which guideline-recommended strategies are effective for secondary prevention of USD. Randomized clinical trials are not yet on the horizon, and so our findings hold the promise of rapidly expanding the evidence base for optimal care of USD and shift the clinical practice paradigm for USD towards primary care providers so that more Veterans with USD can receive effective stone prevention. Specific Aims: We propose the following specific aims: 1) Determine which prevention measures are associated with lower rates of USD recurrence in the VHA; 2) Evaluate how VHA providers are currently implementing prevention measures for USD; and 3) Identify current barriers to implementing effective prevention measures for USD in the VHA. We hypothesize the following: 1) prevention measures such as screening for primary hyperparathyroidism, 24- hour urine testing, and prescription of stone-related medications are associated with longer periods of time to recurrent USD and/or fewer stone events; 2) primary care providers are less likely than specialty providers to implement prevention measures for USD; and 3) each provider type face unique barriers that reduce utilization of effective stone prevention measures. Methodology: Aim 1 will identify a national cohort of Veterans with incident or recurrent USD between 2010 and 2016 and use methods that mimic randomized clinical trials to identify which guideline-recommended measures lead to longer times to a second USD event or fewer USD events. Aim 2 will examine the proportion of patients who receive care from primary care, nephrology, and urology providers following their index stone event and identify which providers are more or less likely to implement each prevention measure. Aim 3 will conduct national surveys with primary care, nephrology, and urology providers affiliated with the VHA to identify barriers to implementation of effective stone prevention measures. Next Steps/Implementation: The VHA is ideally positioned to support comparative effectiveness studies to determine which best practice guidelines are most effective at reducing USD recurrence. The proposed research will define more clearly best practice management of USD, evaluate how VHA providers are currently implementing prevention measures, and identify barriers that obstruct uniform adoption of best practice management of USD across the VHA. We anticipate that our findings will inform the design of prospective clinical trials (where feasible) and facilitate diffusion of best USD care practices within and beyond the VHA.