Home-based conservative care model for advanced kidney disease

项目摘要/摘要 背景：保守治疗(CC)是不愿接受保守治疗的退伍军人的重要治疗选择 为他们的晚期慢性肾脏疾病(CKD)寻求维持性透析，并提供全人、 采用多学科方法进行护理，重点是减缓疾病进展、主动症状 管理，提前护理计划，并提供适当的姑息治疗。最近的证据来自 对其他发达国家CC项目的观察研究表明，对于老年患者(≥75岁) 有严重的并发症和功能限制，透析可能不会有意义地延长生存期或 提高生活质量，超越CC所能实现的目标。尽管每7名患有晚期慢性肾脏病的退伍军人中就有1人这样做 不进行透析，退伍军人事务部内没有正式的CC计划，几乎没有协调一致的努力来 在非退伍军人管理局的环境中建立这些计划。虽然退伍军人事务部目前不存在CC计划，但许多 在其他发达国家找到的、退伍军人、家庭和 医疗保健提供者可以在退伍军人事务部的以家庭为基础的初级保健(HBPC)计划中找到。HBPC提供 为患有多发病和功能受限的退伍军人提供基于家庭的多学科初级护理 目标是支持退伍军人的生活质量，减少疾病的并发症，直到生命的尽头。 我们假设HBPC的多学科护理(MDC)框架是理想的起点 为退伍军人建立第一个CC计划，为具有高级CKD的退伍军人。重要意义：目前的提案是 与HBPC、退伍军人事务部老年医学和长期护理数据分析中心的运营合作伙伴合作，以及 退伍军人事务部国家肾脏计划。它解决了HSRD的优先事项，即改善获得护理的机会、医疗保健价值、 通过增加HBPC和HBPC的证据基础来管理复杂的慢性病和长期护理 用晚期慢性肾脏病填补退伍军人的突出护理空白。创新和影响：提案将引领 到：1)首次全面调查与收到HBPC有关的CKD相关结果；和2) 为退伍军人中患有晚期CKD的退伍军人创建第一个循证CC计划，如果不是 国家。具体目标：目标1：评估HBPC MDC模型对CKD特定结果的影响； 和目标2：评估通过MDC提供的新CC计划的可行性和可接受性 晚期CKD退伍军人及其照顾者和临床医生HBPC的基础设施和探索 本计划的初步成果。方法：目标1是一个模拟的假设比较 使用观察数据对患有晚期癌症的退伍军人进行全国回顾队列的有效性试验 CKD。我们将使用关联的退伍军人事务部和联邦医疗保险数据，并使用全新的Natural进行增强退伍军人病历审查 语言处理软件，以确定HBPC提供的不同模式的MDC对 晚期慢性肾脏病的下游治疗实践。AIM 2是一项随机试点试验，共有30名退伍军人参加 晚期CKD及其照顾者和临床医生使用人种学研究方法评估可行性 通过现有的MDC基础设施提供的针对高级CKD的新CC计划的可接受性 弗吉尼亚州普吉特湾医疗保健系统的HBPC项目。我们还将使用病历审查和 收集有关慢性肾脏病进展、生活质量、目标一致性护理、照顾者的信息的系列调查 负担、临床医生的工作以及医疗保健利用率和成本。下一步：我们的建议是一项基础性和 我们努力扩大晚期CKD的治疗选择，并创造一个可扩展、 可持续、有效的退伍军人慢性肾脏病治疗模式。这些发现将会被广泛地 通过出版物、在国家会议上的发言和联合国的专业网络传播 与国家退伍军人管理局的政策制定者有高度联系的研究团队成员。

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.