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

项目总结 在美国，有500多万人患有肝硬变。最近的全国数据显示，59%的 2001-2013年间，肝硬变患病率增加，肝硬变死亡率增加52%。尽管有效 用新的直接作用抗病毒药物根除丙型肝炎，减轻慢性肝病和 肝细胞癌将继续上升，导致每年高达106亿美元的医疗费用。 然而，由于劳动力的原因，肝硬变的管理非常复杂，需要专门的培训 短缺，82%的肝硬变相关住院发生在非移植医院，只有45%的肝硬变 患者在住院一年内去看胃肠病专家或肝病专家。克服障碍，实现 通过远程医疗获得特殊护理可能是可行的，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，这种方法还没有在肝硬变中得到严格的研究。 拟议的研究通过以下创新填补了肝硬变护理管理方面的空白：1) 使用迄今为止最大的多中心数据库确定高质量肝硬变护理的可修改障碍；2) 使用实施科学原则为快速采用量身定做专门针对肝硬变的远程保健计划 临床实践；以及3)向地理位置遥远和不同的地点提供远程医疗干预。这个 远程保健可以改善肝硬变患者的护理机会和质量的假设将通过 以下是相互关联的具体目标：(1)调查获得专科护理如何影响护理过程和 在国家退伍军人管理局队列中的临床结果，(2)进行定性访谈，以探索障碍和 在低专科和高专科临床医生中促进获得护理和远程医疗的潜在用途-护理- 访问网站，以及(3)试行远程医疗干预，为患有以下疾病的患者提供及时的肝病护理 在两家社区医院开展肝硬变并发症培训，并通过以下问题加强非专家人员培训- 以学习为基础。该项目的目标是确定可修改的因素，以改善为 并确定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，肝病专家，也是假说驱动的临床研究员 宾夕法尼亚大学。她在以病人为中心和观察性研究方面的经验和硕士学位 在卫生服务和结果研究方面，她已经为执行项目目标做好了准备。建议数 研究将与精心构建的指导相结合，由具有互补专业知识的教职员工进行。 机构支持，以及先进观察方法、临床试验、信息技术、 和实施学。这一奖励和保护时间将允许申请者建立一个独立的 NIH资助的研究生涯，并成为以技术为基础的方法的领导者，以改善 慢性肝病，这是一个迄今缺乏的领域，并有可能应用于其他慢性疾病。

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.