Restructuring Epilepsy Care: Organizational Dynamics and Quality

描述(由申请人提供)： 背景：癫痫(一种以反复发作为特征的神经系统疾病)是退伍军人管理局日益关注的问题，因为它服务于两个日益增长的高风险人群：创伤性脑损伤(TBI)患者和老年人。患有癫痫的退伍军人人数不断增加，以及由此产生的在更有效地管理护理的同时改善机会的需求，导致在09财年创建了四个地理癫痫卓越中心(ECoE)。COE方法源于改善分娩护理的需要，但其作为一种护理模式的有效性尚未得到研究。我们试图使用关系协调(RC)框架来审查ECOE模式的影响，以此来了解ECOE结构对退伍军人管理局提供者之间相互依存关系的影响。使用RC框架的研究表明，在患者和提供者处理不可预测的慢性病，并必须在时间有限的情况下协调多个机构和提供者的护理时，如癫痫，参与者之间的沟通和关系的质量既影响护理的及时性，也影响护理的质量。这项研究试图检验癫痫护理结构的变化如何与RC以及癫痫护理的质量和获得途径相关联。目标1：描述在实施经社理事会倡议前后癫痫护理的质量和可获得性的变化。目标2：描述四个地域生态环境和区域中心实施的护理结构/流程的变化与每个区域生态环境中癫痫护理小组成员之间的关系。目的3：确定不同地域的癫痫患者在获得VA癫痫治疗的途径和质量方面的差异是否与RC相关。方法：这项为期四年的对比案例研究将使用退伍军人管理局的住院、门诊和药房数据来确定患有癫痫的退伍军人，并从ECOE内按癫痫慢性病和癫痫控制分层的随机样本中提取医疗表数据，以确定在整个ECOE实施过程中退伍军人管理局的护理质量和获得护理的机会的变化(2008财年至2014财年)。为了研究资源中心和结构变化之间的联系，我们将首先对每个中心的工作人员进行资源中心调查，并从涉及每个中心的4个轮辐中选择轮辐；轮辐将根据每个中心内的高转介和低转介进行选择。然后，我们将利用调查结果从每个被调查的地点挑选个人进行半结构化访谈，以获得关于护理组织的更丰富的细节，以及每个经社理事会癫痫护理小组为改善护理质量和获得护理的机会而使用的具体创新方法。最后，我们将使用多变量模型将提供者之间的RC和癫痫临床结果联系起来，以确定RC与癫痫护理质量和获得的改善之间的关联程度。影响：这项研究将通过展示ECOE护理模式对临床结果的影响，为退伍军人事务部的利益相关者提供有价值的信息。我们的发现将为评估COE模式在其他疾病护理和次级专科护理的轴辐式模式中的价值奠定基础。识别质量差距为干预措施提供了具体目标，这些干预措施将对患者结局和系统利用率产生最大影响。虽然这项研究侧重于VA癫痫的治疗，但在VA以外的COE模型中没有类似的研究。因此，这项研究的发现可能会为其他疾病的VA护理和非VA癫痫护理提供洞察力。最后，我们纳入RC框架有助于实现科学，因为我们提供了对COE结构对VA提供者之间相互依赖的影响的理解，并建议了可用于同时改善RC和癫痫护理的特定方面的特定类型的干预。

DESCRIPTION (provided by applicant): Background: Epilepsy (a neurological disorder characterized by recurrent seizures) is a growing concern for the VA as it serves two growing populations at high risk for the disorder: individuals with traumatic brain injury (TBI) and the elderly. The growing number of Veterans with epilepsy and the resultant need to improve access while more effectively managing care led to the creation of four geographic Epilepsy Centers of Excellence (ECOEs) in FY09. The COE approach arose out of the need to improve delivery care but has yet to be studied for its effectiveness as a model of care. We seek to examine the impact of the ECOE model using the relational coordination (RC) framework as way to understand the impact of the ECOE structure on the interdependencies between VA providers. Research using the RC framework has demonstrated that in situations where patients and providers deal with an unpredictable chronic illness and have to coordinate care across multiple facilities and providers under time-constrained conditions such as in epilepsy, the quality of communication and relationships among participants affects both the timeliness and quality of care. This study seeks to examine how changes in the structure of epilepsy care are associated with RC and with quality of and access to epilepsy care. Objective 1: Describe changes in quality of and access to epilepsy care before and after ECOE initiative implementation. Objective 2: Describe the associations between changes in the structure/ processes of care implemented by the four geographic ECOEs and RC among epilepsy care team members in each ECOE. Objective 3: Determine whether variations in access to and quality of VA epilepsy care among geographic ECOEs are associated with RC. Methods: This four-year comparative case study will use VA inpatient, outpatient, and pharmacy data to identify Veterans with epilepsy, and medical chart abstraction data from a random sample stratified within ECOE by epilepsy chronicity and seizure control to identify changes in quality of and access to care in the VA throughout ECOE implementation (FY08-FY14). In order to examine the associations between RC and structural change we will first administer RC surveys to staff from each hub, and from 4 spokes who refer to each hub; the spokes will be selected based on high and low referrals within each hub. We will then use survey results to select individuals from each location surveyed for semi-structured interviews to obtain richer details regarding the organization of care and specific innovative approaches used by epilepsy care teams in each ECOE to improve the quality of and access to care. Finally, we will link RC among providers, and epilepsy clinical outcomes to determine the extent to which RC is associated with improvements in quality of and access to epilepsy care using multivariable models. Impact: This study will provide valuable information for VA stakeholders through demonstrating the impact of the ECOE model of care on clinical outcomes. Our findings will lay the foundation for assessing the value of the COE model for care of other diseases and hub-and-spoke models of subspecialty care. Identification of quality gaps provides specific targets for interventions that will have the greatest impact on patient outcomes and system utilization. While this study focuses on VA epilepsy care, no similar studies of a COE model exist outside the VA. Thus findings from this study may provide insights regarding care models for both VA care of other diseases for which a COE model may be considered, and for non-VA epilepsy care. Finally, our inclusion of the RC framework contributes to implementation science by providing an understanding of the impact of the COE structure on interdependencies among VA providers, and suggesting specific types of interventions that may be used to improve RC and specific aspects of epilepsy care simultaneously.