Impact of Mental Illness on Veterans' Palliative Care Access and Outcomes

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DESCRIPTION (provided by applicant): This study focuses on the intersection of depression and anxiety (DEP/ANX) and palliative care (PC) for Veteran inpatients with life-limiting illnesses. The long-term goal is to improve Veteran mental health and quality of life. The proposed research would be carried out at the James J Peters VAMC REAP, by Melissa Garrido, PhD, a junior investigator with training in mental health services research and gerontology. There are two research phases of this proposal. In the first phase, the goals are to quantify the magnitude of the relationship between pre-existing and newly diagnosed DEP/ANX and outcomes (Aim 1: ICU admissions and readmissions; Aim 2: costs of care). In both aims, the following will be tested: a) The hypothesis that these relationships are moderated by receipt of PC; b) The hypothesis that the moderating effect of PC will be increased with the addition of receipt of MHC; and c) The relative effect of PC versus PC+MHC for Veterans with different combinations of physical illnesses and DEP/ANX. These aims will be addressed via secondary analysis of Fiscal Years (FY) 2010-2011 Veteran inpatient administrative data (Medical SAS Inpatient and Outpatient Datasets, Decision Support System National Data Extract [DSS NDE] Clinical Files, Vital Status Files, and combined Health Economics Resource Center [HERC] files) for 30,000 inpatient Veterans across the nation with advanced cancer, HIV/AIDS, or congestive heart failure or chronic obstructive pulmonary disease. Aim 1 will be supplemented with electronic medical records of 200 Veterans who are eligible for an inpatient PC consultation in VISN 3 during FYs 2010-2011. Analyses will account for repeated hospitalizations and clustered data, and will address the fact that similar factors may influence both likelihood of PC and MHC as well as ICU admissions and health care costs. In the second research phase, the results from Aim 1 and Aim 2 will be used to inform the development of a case-finding intervention that identifies which Veterans receiving PC may exhibit reduced symptom burden and reduced ICU use following a MHC consult (Aim 3). The case-finder criteria will be validated in administrative data, and the intervention will be refined with input from clinician stakeholders. Using a non-equivalent comparison group interrupted time-series design, the intervention will be pilot tested at the facility level in VISN 3. In the hird year of the CDA period, an Investigator Initiated Research (IIR) proposal will be developed to test the efficacy of the case-finder intervention in a clustered randomized controlled trial. The information gathered from the CDA and IIR will be used to identify those Veterans who could benefit from specialty MHC as well as to develop and test an intervention to target MHC to Veterans who need it most. The long-term goal is to be an independent VA health services researcher and methods expert working to identify gaps in care and design and evaluate interventions to improve the mental health of seriously ill Veterans. To reach the career goals, several mentored training activities have been proposed. The mentorship team has expertise in intervention design and evaluation, PC, geriatric psychiatry, and quantitative and qualitative health services research. The training goals are to gain skills in intervention design and implementation science, qualitative data analysis, and longitudinal data analysis. These goals will be met with a mixture of courses, readings, cyber and in-person seminars, frequent discussions with mentors, and conferences. Weekly in-person meetings will be held with the co-primary mentors, Kenneth Boockvar, MD, MS, and Joan Penrod, MA, MSW, PhD, and monthly phone calls will be held with the secondary mentors, Christopher Johnson, PhD, and Holly Prigerson, PhD. PUBLIC HEALTH RELEVANCE: Veterans suffer from high rates of life-limiting physical illnesses. Many patients with these illnesses also suffer from depression and/or anxiety (DEP/ANX), which are associated with symptom exacerbation, poor pain control, reduced quality of life, and poor treatment adherence. In non-Veterans, DEP/ANX are associated with increased likelihood of intensive care unit (ICU) admission and readmission and higher care costs. There is some evidence that DEP/ANX treatment might reduce costs and unnecessary utilization. It is unclear, however, whether palliative care (PC) is sufficient to address DEP/ANX among veterans with life-limiting illnesses, and when mental health care (MHC) (medications and/or psychotherapy) is needed as well. Understanding relationships among illness characteristics and need for or benefit from MHC in addition to the psychosocial support provided as part of PC is important for the VHA's abilities to prioritize care improvement efforts and provide Veteran-centered care.