Developing technology-based approaches to improve access and quality of care in cirrhosis

项目摘要 肝硬化影响美国超过500万人。最近的国家数据显示， 从2001年到2013年，肝硬化患病率增加，肝硬化死亡率增加52%。尽管有效 使用新的直接作用抗病毒药物根除丙型肝炎（HCV），慢性肝病的负担， 肝细胞癌将继续上升，导致每年高达106亿美元的医疗保健费用。 肝硬化管理是非常复杂的，需要专门的培训，但是，由于劳动力 由于器官短缺，82%的肾移植相关住院发生在非移植医院，只有45%的肾移植相关住院发生在非移植医院。 患者在住院一年内看胃肠病学家或肝病学家。克服障碍， 通过远程医疗，获得专科护理可能是可行的，这在丙型肝炎病毒治疗、艾滋病毒和 然而，在其他慢性疾病中，这种方法尚未在肝硬化中进行严格的研究。 拟议的研究通过以下创新填补了肝硬化护理管理的空白： 使用迄今为止最大的多中心数据库确定高质量肝硬化护理的可修改障碍; 2） 使用实施科学原则定制肝硬化特定的远程医疗计划，以快速采用 临床实践;以及3）向地理上遥远和不同的地点提供远程保健干预。的 远程医疗可以改善肝硬化护理的可及性和质量的假设将通过 以下相互关联的具体目标：（1）调查获得专业护理的机会如何影响护理过程， 全国VA队列中的临床结局，（2）进行定性访谈以探索障碍， 在低级和高级专科护理的临床医生中促进获得护理和远程保健的潜在用途， 访问站点，以及（3）对远程医疗干预进行试点测试，为患有以下疾病的患者提供及时的肝脏病学护理 在两个社区医院的肝硬化并发症，并加强非专家提供培训，通过问题- 基于学习。该项目的目标是确定可改变的因素，以改善向老年人提供高质量的护理。 我们的目标是，通过建立远程保健战略的可行性，以增加获得专科护理的机会。 PI是医学助理教授，肝病学家和假设驱动的临床研究人员， 宾夕法尼亚大学她在以患者为导向的观察性研究和硕士学位方面的经验 在卫生服务和成果研究准备她执行项目的目标。拟议 研究将与具有互补专业知识的教师精心设计的指导相结合， 机构支持，先进的观察方法，临床试验，信息技术， 和实施科学。这个奖项和保护的时间将允许申请人建立一个独立的 NIH资助的研究事业，并成为以技术为基础的方法，以改善医疗服务， 慢性肝病，这是一个迄今为止缺乏的领域，并具有对其他慢性疾病的潜在应用。

PROJECT SUMMARY Liver cirrhosis affects greater than 5 million individuals in the United States. Recent national data show a 59% increase in cirrhosis prevalence and a 52% increase in cirrhosis mortality from 2001-2013. Despite effective hepatitis C (HCV) eradication with new direct-acting antivirals, the burden of chronic liver disease and hepatocellular carcinoma will continue to rise, resulting in up to $10.6 billion in annual health care costs. Cirrhosis management is highly complex and requires specialized training, however, due to workforce shortages, 82% of cirrhosis-related hospitalizations occur at non-transplant hospitals and only 45% of cirrhotic patients see a gastroenterologist or hepatologist within one year of hospitalization. Overcoming barriers to access to specialty care may be feasible with telehealth, which has shown promise in HCV treatment, HIV, and other chronic diseases, however, this approach has not been rigorously investigated in cirrhosis. The proposed research fills gaps in cirrhosis care management through the following innovations: 1) identifying modifiable barriers to high quality cirrhosis care using the largest, multi-center database to date; 2) tailoring a telehealth program specific to cirrhosis using implementation science principles for rapid adoption into clinical practice; and 3) delivering a telehealth intervention to geographically distant and diverse sites. The hypothesis that telehealth may improve the access and quality of care in cirrhosis will be pursued through the following interrelated Specific Aims: (1) investigate how access to specialty care impacts process of care and clinical outcomes among a national VA cohort, (2) conduct qualitative interviews to explore barriers and facilitators of access to care and potential uses for telehealth among clinicians at low and high specialty-care- access sites, and (3) pilot-test a telehealth intervention to provide timely hepatology care to patients with cirrhosis complications at two community hospitals, and enhance non-expert provider training through problem- based learning. The project aims will identify modifiable factors to improve the delivery of high-quality care for cirrhosis and establish the feasibility of a telehealth strategy to increase access to specialty care. The PI is Assistant Professor of Medicine, a hepatologist, and hypothesis-driven clinical researcher at the University of Pennsylvania. Her experience in patient-oriented and observational research and a Master's in Health Services and Outcomes Research have prepared her to execute the project aims. The proposed research will be combined with carefully structured mentorship by faculty with complementary expertise, institutional support, and coursework in advanced observational methods, clinical trials, information technology, and implementation science. This award and protected time will allow the applicant to build an independent NIH-funded research career and become a leader in technology-based approaches to improve care delivery in chronic liver disease, an area that is lacking to date, and with potential applications to other chronic diseases.