Optimizing Access, Appropriateness, and Quality of Minimally Invasive Procedures for Veterans

优化退伍军人微创手术的可及性、适当性和质量

• 批准号: 10392911
• 负责人: Celina M Yong
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-02-01 至 2024-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10392911
• 关键词: Address; Affect; Aortic Valve Stenosis; Benefits and Risks; Cardiac Surgery procedures; Cardiovascular system; Caring; Complex; Coronary Artery Bypass; Data; Databases; Decision Aid; Decision Making; Demographic Factors; Development; Diffusion; Discipline; Elderly; Evidence based intervention; Face; Gender; Geographic Locations; Grant; Growth; Health Care Costs; Health Personnel; Health Services Accessibility; Healthcare; Intervention; Interview; Left; Life; Logistic Regressions; Medical; Medicare; Mentors; Methodology; Methods; Modeling; Operative Surgical Procedures; Patients; Persons; Physicians; Population; Preparation; Procedures; Provider; Quality of life; Race; Randomized; Research; Resources; Risk; Sampling; Savings; Science; Services; Site; Socioeconomic Status; Specialized Center; Stenosis; Structure; Technology; Testing; Therapeutic; Time; Training; Translating; Travel; Veterans; Work; aortic valve disorder; aortic valve replacement; barrier to care; base; career; comorbidity; contextual factors; design; effective intervention; experience; geographic barrier; health care service utilization; high risk; human old age (65+); implementation science; implementation strategy; improved; innovation; insight; military veteran; minimally invasive; mortality; multi-site trial; novel; older patient; patient population; percutaneous coronary intervention; personalized decision; personalized predictions; prototype; routine care; structural heart disease; tool; treatment comparison; treatment disparity; uptake; valve replacement; web site

The last five years have seen a paradigm shift in healthcare: new minimally invasive treatments are now available that can effectively replace surgery for elderly, comorbid patients. The most striking example is Transcatheter Aortic Valve Replacement (TAVR), the first major minimally invasive structural heart disease treatment to be disseminated nationally. TAVR is a life-saving option for the approximately 87,000 Veterans nationwide who suffer from severe aortic stenosis, and thereby face a 50% mortality rate within two years if left untreated. Preliminary data suggest that the novel complexities associated with TAVR diffusion significantly impact vulnerable patient populations. Based on prior data, one key mechanism for these disparities may be that vulnerable patient populations are less equipped to make informed decisions about treatment. Driven by the hypothesis that vulnerable Veteran populations experience unequal treatment with TAVR, but that decision support to routinely assess appropriateness and reduce barriers to care for Veterans can reduce these differences, the aims of this proposal are to: (1) Identify patient level factors that influence cardiovascular procedural treatment on the spectrum from minimally invasive (newer: TAVR and older: PCI) to invasive (older: CABG, SAVR) within the VA, categorizing high and low access groups, with non- VA data comparison. Multivariate, hierarchical logistic regression will be used to determine the association of patient level factors, including demographic and VA-specific contextual factors (e.g., percent service connection, proximity to VA procedure site, use of Veterans Choice or Medicare) with procedural use, identifying “low” and “high” access profile groups. I hypothesize that older, established cardiovascular procedures will show fewer inequities in care compared to the newest paradigm of care, TAVR. (2) Identify decisional needs and barriers to achieving appropriate TAVR treatment from the perspectives of Veterans (stratified into low and high access groups as defined by Aim 1) and their healthcare providers. I will use an explanatory mixed methods design to conduct semi-structured interviews with a stratified sample of low and high access profile Veterans referred for TAVR from multiple states and their providers to inform development of a pilot intervention in Aim 3. I hypothesize that poor understanding of individualized risks and benefits are a major limitation to appropriate TAVR referrals, with geographic barriers and difficulty using Veterans Choice options particularly identified among low access profile Veterans. (3) Build and pilot a novel individualized decision-making tool and patient facing website to improve both appropriateness and access to care, along with a strategy for implementation into routine VA care. Using TAVR as a model, I will develop and validate the feasibility of a prototype physician-facing decision aid for incorporation into routine VA care that predicts individualized risks and benefits of TAVR, as well as a patient-facing website that addresses barriers to care, such as mapping proximity and quality of the nearest TAVR sites for geographically remote Veterans who may require use of Veterans Choice. Through the successful execution of this work, for the first time, potential inequities in access to TAVR among vulnerable Veterans will be identified, and insights will be revealed into the gaps in decision making support for Veterans and their physicians that may contribute to these differences. Additionally, this work will advance the field by piloting the first evidence-based intervention to systematically improve the appropriateness of care for Veterans receiving minimally invasive procedures by generating individualized risk-benefit profiles for treatment, with further online innovative decisional support resources. This will serve as a model for a host of novel minimally invasive treatments now becoming available across multiple therapeutic disciplines.

过去五年见证了医疗保健的范式转变：新的微创治疗是 现在可以有效地取代老年患者的手术。最引人注目的例子是 经导管主动脉瓣置换术(TAVR)--第一种主要的微创结构性心脏病 治疗将在全国范围内传播。TAVR是大约87,000名退伍军人的救命选择 全国范围内患有严重主动脉狭窄的患者，因此在两年内面临50%的死亡率，如果 不治身亡。初步数据表明，与TAVR扩散相关的新复杂性显著 影响脆弱的患者群体。根据先前的数据，造成这些差异的一个关键机制可能是 脆弱的患者群体缺乏做出关于治疗的知情决定的能力。 由这样的假设驱动的，即脆弱的退伍军人群体在 TAVR，但该决定支持定期评估适当性并减少照顾退伍军人的障碍 为了减少这些差异，本提案的目的是：(1)确定患者水平因素， 微创对心血管程序性治疗的影响(较新：TAVR和 年龄较大的：在退伍军人管理局内，从PCI)到侵入性(较早的：CABG、SAVR)，对高访问组和低访问组进行分类，非 VA数据比对。将使用多变量、分层Logistic回归来确定 患者水平因素，包括人口统计和退伍军人管理局特定的背景因素(例如，服务百分比 连接，靠近退伍军人管理局手术地点，使用退伍军人选择或医疗保险)和程序使用， 标识“低”和“高”访问配置文件组。我假设较年长的，已确立的心血管疾病 与最新的护理范例TAVR相比，手术过程中显示的不平等现象较少。(2)识别 从退伍军人的角度看实现适当的TAVR治疗的决策需求和障碍 (根据目标1的定义分为低访问组和高访问组)及其医疗保健提供者。我将使用一个 解释性混合方法设计，对Low和Low和 从多个州及其提供者向TAVR推荐的高访问配置文件退伍军人向发展提供信息 对AIM的试点干预。我假设对个性化风险和收益的缺乏理解是一种 对适当的TAVR转诊的主要限制，地理障碍和使用退伍军人选择的困难 特别是在低访问配置文件的退伍军人中确定的选项。(3)构建和试点个性化的新型 决策工具和面向患者的网站，以提高适当性和获得护理的机会，以及 以及实施到常规退伍军人管理局护理中的战略。以TAVR为模型，进行开发和验证 将面向医生的决策辅助原型纳入常规VA护理的可行性 TAVR的个性化风险和收益，以及一个面向患者的网站，以解决 关怀，例如为地理位置偏远的退伍军人绘制最近TAVR站点的距离和质量地图 可能需要使用退伍军人选择。 通过这项工作的成功执行，第一次，在获得 将确定脆弱退伍军人中的TAVR，并将揭示决策中的差距 为退伍军人和他们的医生提供支持，这可能会导致这些差异。此外，这一点 这项工作将通过试点第一个基于证据的干预措施来系统地改善 退伍军人接受微创手术治疗的适宜性 治疗的个性化风险-收益概况，并提供进一步的在线创新决策支持 资源。这将成为一系列新的微创治疗方法的典范 可跨多个治疗学科使用。