Impact of COVID-19 on implementation and outcomes of VA's Life-Sustaining TreatmentDecisions Initiative

在临床恶化之前进行的前瞻性护理对话目标(GoCC)是 高质量、以患者为中心的护理。如果做得好，GoCC允许医疗保健提供者定制临终关怀 患者价值和改善患者、护理人员、提供者和医疗保健系统的关键结果。 鉴于促进GoCC的结构和程序的需要，退伍军人事务部国家健康伦理中心 CARE于2018年在所有退伍军人管理局实施了生命维持治疗决定倡议(LSTDI)，以 为临床恶化风险较高的退伍军人推广GoCC标准化记录。截至早些时候 到2020年，积极主动的政府间合作机制仍未得到充分利用。冠状病毒大流行的爆发加强了 GoCC指导临终关怀的必要性和重要性，作为创新的催化剂 LSTDI实施。为了应对大流行，指导方针和非专业媒体在 患者和提供者主动讨论和记录GoCC。退伍军人事务部内外的许多站点 开发创新以促进积极主动的GoCC，包括向高危患者(例如，有 痴呆症)，通过远程保健举行GoCC(这些敏感讨论的一种新方式)，以及任务和 培训以前未被LSTDI联系到的进行GoCC的门诊提供者。[至少40伏安 与大流行前相比，2021年各设施的门诊率有所增加。] [然而，目前尚不清楚这些站点如何增加和保持GoCC率，或者是否由CoVID催化 LSTDI实施创新提高了GoCC费率，但牺牲了GoCC质量或公平性。我们的 假设一些机构在大流行期间优先实施门诊LSTDI，实现 可持续地增加政府间合作中心的覆盖面和质量，而不会加剧全球政府间合作中心之间的差距 黑人退伍军人。通过对LSTDI在选定地点的实施情况的密切评估，我们将确定可持续的 可在退伍军人事务部传播的大流行催生的创新，以改进LSTDI实施和 提供高质量、公平、以病人为中心的临终关怀，即使在大流行消退之后也是如此。] 我们的顺序解释性混合方法研究旨在[全面评估长期 COVID大流行对LSTDI的实施以及GCC的频率、质量和公平的影响]。 我们从时间序列分析开始，研究COVID如何影响退伍军人管理局的LSTDI实施 设施，注意退伍军人服务范围的[持续]变化和提供者的采用情况(目标1)。我们会 然后利用时间序列和比例风险分析来评估门诊GoCC的质量和公平性， 由LSTDI说明(目标2a)中的国家质量论坛首选实践文件确定，以及 从GoCC到死亡的时间长度，这是积极主动的提前护理计划(目标2b)的标志。最后，在目标3中，我们 将采访来自根据目标1和目标2有目的地选择的[10]个地点的退伍军人、供应商和领导人 确定最佳做法以改进[并保持政府间通信中心的频率、质量和公平， 特别注意吸引黑人退伍军人和痴呆症患者的方法]。调查结果将向 提高LSTDI实施的质量、公平性和可持续性的行动手册。 大流行给退伍军人管理局医疗保健服务带来的变化创造了前所未有的机会 确定实施LSTDI的创新、挑战和意想不到的后果 GoCC在COVID之前、期间和之后提供的临终关怀的质量和公平性的结果。这 研究旨在利用大流行造成的独特情况和紧迫感，并将 产生可用的交付成果：记录最佳实践和催化的创新的实施攻略 受大流行的影响。这项工作得到了我们在国家健康伦理中心的合作伙伴的大力支持 CARE和初级保健办公室帮助推广LSTDI，这对实现 弗吉尼亚授权进行GoCC，以提高临终关怀的质量、公平性和以病人为中心。

Proactive goals of care conversations (GoCCs) conducted in advance of clinical deterioration are a hallmark of high-quality, patient-centered care. When done well, GoCCs allow healthcare providers to tailor end-of-life care to patient values and improve key outcomes for patients, caregivers, providers, and the healthcare system. Given the need for structures and processes to promote GoCCs, the VA National Center for Ethics in Health Care implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) at all VA facilities in 2018 to promote standardized documentation of GoCCs for Veterans at high risk of clinical deterioration. As of early 2020, proactive GoCCs remained vastly underutilized. The onset of the COVID pandemic reinforced the need for and importance of GoCCs to guide end-of-life care, acting as a catalyst for innovations to LSTDI implementation. In response to the pandemic, guidelines and lay media instilled a new urgency among patients and providers to proactively discuss and document GoCCs. Many sites both within and outside of VA developed innovations to facilitate proactive GoCCs, including outreach to high-risk patients (e.g., those with dementia), holding GoCCs by telehealth (a new modality for these sensitive discussions), and tasking and training outpatient providers previously unreached by the LSTDI with conducting GoCCs. [At least 40 VA facilities have increased outpatient GoCCs in 2021 compared with pre-pandemic rates.] [Yet it remains unknown how these sites increased and maintained GoCC rates, or whether COVID-catalyzed LSTDI implementation innovations improved GoCC rates at the expense of GoCC quality or equity. Our hypothesis is that some facilities prioritized outpatient LSTDI implementation during the pandemic, achieving sustainable increases in both reach and quality of GoCCs without exacerbating disparities in GoCCs among Black Veterans. From close evaluations of LSTDI implementation at selected sites, we will identify sustainable innovations catalyzed by the pandemic that can be spread across VA to improve LSTDI implementation and delivery of high-quality, equitable, patient-centered end-of-life care, even after the pandemic recedes.] Our sequential explanatory mixed methods study is designed to [comprehensively assess the long-term impact] of the COVID pandemic on LSTDI implementation and the frequency, quality, and equity of GoCCs. We begin with time series analyses to examine how COVID affected LSTDI implementation across VA facilities, with attention to [sustained] changes in reach to Veterans and adoption by providers (Aim 1). We will then leverage time series and proportional hazard analyses to assess quality and equity of outpatient GoCCs, as determined by documentation of National Quality Forum preferred practices in LSTDI notes (Aim 2a), and length of time from GoCC to death, a marker of proactive advance care planning (Aim 2b). Finally, in Aim 3, we will interview Veterans, providers, and leaders from [10] sites purposively selected based on Aims 1 and 2 findings to identify best practices to improve [and maintain frequency, quality, and equity of GoCCs, with special attention to approaches to engage Black Veterans and patients with dementia]. Findings will inform a playbook to improve quality, equity, and sustainability of LSTDI implementation. The changes wrought by the pandemic to VA healthcare delivery created an unprecedented opportunity to identify innovations, challenges, and unintended consequences in implementing the LSTDI, as well as outcomes of GoCCs on quality and equity of end-of-life care delivered before, during, and after COVID. This study is designed to leverage the unique circumstance and sense of urgency created by the pandemic and will produce a usable deliverable: an implementation playbook capturing best practices and innovations catalyzed by the pandemic. This work is strongly supported by our partners in the National Center for Ethics in Health Care and the Office of Primary Care to help spread the LSTDI, and it is of central importance to achieving the VA mandate to conduct GoCCs to improve the quality, equity, and patient-centeredness of end-of-life care.