Home-based conservative care model for advanced kidney disease

项目总结/文摘

PROJECT SUMMARY/ABSTRACT Background: Conservative care (CC) is an important therapeutic option for Veterans who do not wish to pursue maintenance dialysis for their advanced chronic kidney disease (CKD) and offers a whole-person, multidisciplinary approach to care that is focused on slowing disease progression, active symptom management, advance care planning, and provision of appropriate palliative care. Recent evidence from observational studies of CC programs in other developed countries indicate that for older patients (aged ≥75 years) with significant comorbidity and functional limitation, dialysis may not meaningfully lengthen survival or improve quality of life beyond what can be achieved with CC. Although 1 in 7 Veterans with advanced CKD do not pursue dialysis, there are no formal CC programs within the VA and few, if any, concerted efforts to establish these programs in non-VA settings. While CC programs do not currently exist in the VA, many of the elements of CC programs found in other developed countries and that are desirable to Veterans, families, and healthcare providers can be found in the VA’s Home-Based Primary Care (HBPC) program. HBPC provides home-based multidisciplinary primary care to Veterans with multimorbidity and functional limitation with the goal of supporting Veterans’ quality of life and mitigating the complications of illness through to the end of life. We hypothesize that the multidisciplinary care (MDC) framework of HBPC serves as the ideal starting ground to build the VA’s first CC program for Veterans with advanced CKD. Significance: The current proposal is a collaboration with operational partners in HBPC, VA Geriatrics and Extended Care Data Analysis Center, and the VA National Kidney Program. It addresses HSRD priorities of improving access to care, healthcare values, management of complex chronic illness, and long-term care by increasing the evidence base for HBPC and filling outstanding care gaps for Veterans with advanced CKD. Innovation and Impact: The proposal will lead to: 1) the first comprehensive investigation of CKD-relevant outcomes associated with receipt of HBPC; and 2) the creation of the first evidence-based CC program for Veterans with advanced CKD in the VA, if not the nation. Specific Aims: Aim 1: To evaluate the impact of the HBPC MDC model on CKD-specific outcomes; and Aim 2: To assess the feasibility and acceptability of a novel CC Program delivered through the MDC infrastructure of HBPC among Veterans with advanced CKD, their caregivers and clinicians and explore preliminary outcomes of this Program. Methodology: Aim 1 is an emulated hypothetical comparative effectiveness “trial” using observational data for a national retrospective cohort of Veterans with advanced CKD. We will use linked VA and Medicare data and augmented VA medical record review using novel natural language processing software to determine the impact of different patterns of MDC provided by HBPC on downstream treatment practices for advanced CKD. Aim 2 is a randomized pilot trial of 30 Veterans with advanced CKD, their caregivers and clinicians using ethnographic research methods to assess the feasibility and acceptability of a novel CC Program for advanced CKD delivered through the existing MDC infrastructure of the HBPC program at VA Puget Sound Health Care System. We will also use medical record review and serial surveys to collect information on CKD progression, quality of life, goal concordant care, caregiver burden, clinician effort, and healthcare utilization and costs. Next Steps: Our proposal is a foundational and necessary step in our efforts to expand treatment options for advanced CKD and to create a scalable, sustainable, and effective model of CC for Veterans with advanced CKD. The findings will be widely disseminated through publications, presentations at national conferences and professional networks of the study team members who are highly connected with policy makers at national VA agencies.