Quality of Care for Hepatitis C in Veterans Who Are Homeless

无家可归的退伍军人的丙型肝炎护理质量

• 批准号: 9082646
• 负责人: Donald Keith McInnes
• 金额: --
• 依托单位: EDITH NOURSE ROGERS MEMORIAL VETERANS HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-07-01 至 2019-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9082646
• 关键词: Achievement; Achievement; Alcohol or Other Drugs use; Alcohol or Other Drugs use; Antiviral Therapy; Blood; Blood; Caring; Caring; Centers for Disease Control and Prevention (U.S.); Centers for Disease Control and Prevention (U.S.); Cessation of life; Cessation of life; Characteristics; Characteristics; Cirrhosis; Cirrhosis; Clinical; Clinical; Cohort Analysis; Cohort Analysis; Comorbidity; Continuity of Patient Care; Continuity of Patient Care; Data; Data; Data Collection; Data Collection; Databases; Databases; Decision Making; Decision Making; Diagnosis; Diagnosis; Direct Costs; Direct Costs; Disease; Disease; Drug Costs; Drug Costs; Emergency Care; Emergency Care; Emergency Situation; Ensure; Ensure; Goals; Goals; Health; Health; Healthcare; Healthcare; Healthcare Systems; Healthcare Systems; Hepatitis; Hepatitis; Hepatitis C; Hepatitis C; Hepatitis C virus; Hepatitis C virus; High Prevalence; High Prevalence; Homeless persons; Homeless persons; Homelessness; Homelessness; Housing; Housing; Human; Human; Individual; Individual; Inpatients; Intervention; Intervention; Interview; Interview; Lead; Learning; Learning; Malignant neoplasm of liver; Malignant neoplasm of liver; Measures; Measures; Medical; Medical; Medical center; Medical center; Mental Health; Mental Health; Methods; Methods; Modeling; Modeling; Needle Sharing; Needle Sharing; Pathway interactions; Pathway interactions; Patients; Patients; Pattern; Pattern; Performance; Performance; Persons; Persons; Pharmaceutical Preparations; Pharmaceutical Preparations; Population; Population; Post-Traumatic Stress Disorders; Post-Traumatic Stress Disorders; Prevalence; Prevalence; Primary Health Care; Primary Health Care; Primary carcinoma of the liver cells; Primary carcinoma of the liver cells; Process; Process; Public Health; Public Health; Quality of Care; Quality of Care; Research; Research; Retrospective cohort; Risk; Risk; Self Management; Self Management; Services; Services; Site; Site; Site Visit; Site Visit; Social support; Social support; Specialist; Specialist; Substance Use Disorder; Substance Use Disorder; System; System; Testing; Testing; Time; Time; Time Study; Veterans; Veterans; Viral; Viral; Visit; Visit; Vulnerable Populations; Vulnerable Populations; Work; Work; base; base; burden of illness; burden of illness; cost; cost; demographics; demographics; disorder prevention; experience; experience; health administration; health administration; health care availability; implementation research; implementation research; improved; improved; injection drug use; injection drug use; inpatient service; lens; lens; liver injury; liver injury; medical specialties; medical specialties; mortality; mortality; response; response; study population; study population; supported housing; supported housing; therapy design; therapy design; therapy development; therapy development

 DESCRIPTION (provided by applicant): Background: Despite initiatives to end Veteran homelessness, over 137,000 Veterans were homeless at some point during 2013. Homeless persons, compared to housed, are sicker and have mortality rates 5-9 times higher. Healthcare for homeless Veterans is characterized by discontinuities in care, difficulty adhering to treatment, and frequent use of emergency and inpatient care. Hepatitis C virus (HCV) is an exemplar condition for understanding deficiencies in health systems' care for homeless persons because of the high prevalence in this population (over 20%) and the need for continuity of care in both primary and specialty care. HCV is the most common blood borne disease in the US with 3.2 million persons infected. It causes liver damage, hepatocellular cancer, and death. Quality HCV care involves sequential steps from identification, to linkage to a specialist, treatment initiation and treatment completion. This pathway has been formalized in a model called the HCV Care Continuum. Among those infected with HCV, however, only 50% have been diagnosed, 38% referred to HCV specialty care, 11% put on anti-viral therapy, and 6% achieved sustained viral response (SVR; i.e. cure). Data suggest the percentages for homeless persons are lower. Objectives: The goal of this study is to provide the first system-wide analysis of health care for homeless Veterans, through the lens of HCV care; and then to develop an intervention to spread best practices for homeless HCV care throughout VHA. The aims are: Aim 1: Describe how homeless HCV+ Veterans are distributed among VA medical centers; Aim 2: Evaluate quality of care for homeless and non-homeless Veterans as measured by progress along the HCV Care Continuum and the relationship of quality to patient, facility, and housing characteristics. Aim 3: Develop an intervention to improve HCV care for homeless Veterans, and submit a proposal to pilot test the intervention. Methods: This is a 3-year mixed-methods study combining retrospective cohort analysis of VA databases with qualitative data collection. For quantitative analyses the study population consists of >6.5 million Veterans in VHA care between FY09-14. Two subsets are also analyzed: all homeless Veterans (around 267,000), and HCV+ Veterans who are homeless (around 36,000). Adjusted models will indicate whether degree of homelessness (long-term supportive housing, at-risk of homelessness, or currently homeless) and individual modifiable factors (e.g. PTSD, substance use) and facility characteristics have differential effects on achievement of Continuum measures. In Aim 3, based on the analyses of the 36,000 homeless HCV Veterans in VHA care, we will identify 3 higher and 3 lower performing facilities (on the Care Continuum) based on risk adjusted profiling. We will make site visits and interview stakeholders (e.g. clinicians, staff, Veterans) to learn about best practices, as well as challenge and barriers to providing HCV care to homeless Veterans in their facilities. Findings from qualitative and quantitative data will be incorporated into the design of an intervention. Anticipated impact on Veterans' healthcare: VHA supports efforts to end Veteran homelessness by 2015. Yet it has never assessed system-wide performance to ensure that healthcare for homeless Veterans is accessible, continuous, and engages Veterans in self-management of medical conditions. Such an analysis, using HCV as an exemplar condition, will be conducted in this study. It will identify strengths and weaknesses of VHA hepatitis care for homeless Veterans, pinpointing where breakdowns occur in the treatment pathway. It will also identify several high- and low-performing VA medical centers based on percentage of their HCV+ Veterans who initiated treatment. These sites will be visited to identify best practices and strategies for overcoming barriers. An intervention will be developed to spread best practices through implementation research. These studies will lead to improved care for homeless and non-homeless HCV+ Veterans alike.

 描述（由申请人提供）： 背景：尽管采取了结束退伍军人无家可归的举措，但在2013年的某个时候，仍有超过137，000名退伍军人无家可归。与有住房者相比，无家可归者病情更重，死亡率高出5-9倍。无家可归的退伍军人的医疗保健的特点是不连续的护理，难以坚持治疗，并经常使用紧急和住院治疗。丙型肝炎病毒（HCV）是了解卫生系统对无家可归者护理缺陷的一个典型条件，因为这一人群的患病率很高（超过20%），需要在初级和专科护理中保持连续性。HCV是美国最常见的血液传播疾病，有320万人感染。它会导致肝损伤、肝细胞癌和死亡。高质量的HCV护理包括从识别到与专家联系、治疗开始和治疗完成的连续步骤。这一途径已经在一个称为HCV护理连续体的模型中正式化。然而，在HCV感染者中，只有50%被诊断出来，38%被转诊到HCV专科护理，11%接受抗病毒治疗，6%达到持续病毒应答（SVR;即治愈）。数据显示，无家可归者的比例较低。目的：本研究的目标是通过HCV护理的透镜，为无家可归的退伍军人提供第一个全系统的医疗保健分析，然后制定干预措施，在整个VHA传播无家可归的HCV护理的最佳实践。其目标是：目标1：描述无家可归的HCV+退伍军人是如何分布在VA医疗中心;目的2：评估无家可归和非无家可归的退伍军人的护理质量作为衡量的进展沿着HCV护理连续体和质量的关系，病人，设施和住房特征。目标3：制定一项干预措施，以改善无家可归的退伍军人的HCV护理，并提交一份提案，对干预措施进行试点测试。方法：这是一项为期3年的混合方法研究，将VA数据库的回顾性队列分析与定性数据收集相结合。对于定量分析，研究人群包括2009 - 2014财年期间接受VHA护理的> 650万退伍军人。还分析了两个子集：所有无家可归的退伍军人（约267，000）和无家可归的HCV+退伍军人（约36，000）。调整后的模型将表明无家可归的程度（长期支持性住房，无家可归的风险，或目前无家可归）和个人可修改的因素（如创伤后应激障碍，物质使用）和设施的特点是否对实现连续性措施有不同的影响。在目标3中，基于对接受VHA护理的36，000名无家可归的HCV退伍军人的分析，我们将根据风险调整分析确定3个性能较高和3个性能较低的设施（在护理连续体上）。我们将进行现场访问和采访利益相关者（例如临床医生，工作人员，退伍军人），以了解最佳实践，以及在其设施中为无家可归的退伍军人提供HCV护理的挑战和障碍。从定性和定量数据中得出的结论将纳入干预措施的设计。对退伍军人医疗保健的预期影响：VHA支持到2015年结束退伍军人无家可归的努力。然而，它从未评估过全系统的绩效，以确保无家可归的退伍军人的医疗保健是可获得的，连续的，并使退伍军人参与医疗状况的自我管理。将在本研究中使用HCV作为示例条件进行此类分析。它将确定VHA肝炎护理无家可归的退伍军人的优点和缺点，查明在治疗途径中发生故障的地方。它还将根据启动治疗的HCV+退伍军人的百分比确定几个高性能和低性能的VA医疗中心。将访问这些地点，以确定克服障碍的最佳做法和战略。将制定一项干预措施，通过执行情况研究传播最佳做法。这些研究将改善对无家可归和非无家可归的HCV+退伍军人的护理。