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

精神疾病对退伍军人姑息治疗获取和结果的影响

• 批准号: 8398151
• 负责人: Melissa M Garrido
• 金额: --
• 依托单位: JAMES J PETERS VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2012
• 资助国家: 美国
• 起止时间: 2012-10-01 至 2017-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8398151
• 关键词: AIDS/HIV problem; Accounting; Address; Adherence; Admission activity; Advanced Malignant Neoplasm; Anxiety; Attention; Caring; Characteristics; Chronic Obstructive Airway Disease; Chronic lung disease; Clinical; Computerized Medical Record; Computerized Patient Records; Congestive Heart Failure; Consult; Consultations; Data; Data Analyses; Data Set; Decision Making; Decision Support Systems; Development; Direct Costs; Doctor of Philosophy; Evaluation; Evidence based intervention; Exhibits; Family; Geriatric Psychiatry; Gerontology; Goals; Health; Health Care Costs; Health Services; Health Services Accessibility; Health Services Research; Healthcare; Heart Diseases; Holly; Hospitalization; Inpatients; Intensive Care Units; Intervention; Investigator-Initiated Research; Laboratories; Life; Medical; Medical Records; Melissa; Mental Depression; Mental Health; Mental Health Services; Mental disorders; Mentors; Mentorship; Methods; Modeling; Newly Diagnosed; Outcome; Outpatients; Pain management; Palliative Care; Patient Care; Patients; Persons; Pharmaceutical Preparations; Pharmacotherapy; Pharmacy facility; Phase; Plague; Population; Post-Traumatic Stress Disorders; Psychosocial Assessment and Care; Psychotherapy; Quality of life; Radiology Specialty; Randomized Controlled Trials; Reading; Relative (related person); Research; Research Personnel; Research Proposals; Resources; Series; Services; Strategic Planning; Stress; Symptoms; System; Techniques; Telephone; Testing; Time; Training; Training Activity; Veterans; Vital Status; Work; base; career; case finding; comparison group; cost; court; design; efficacy testing; end of life; health administration; health economics; implementation science; improved; information gathering; medical specialties; meetings; physical conditioning; preference; psychosocial; skills; symposium; symptom management; therapy design; treatment adherence

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.

描述（由申请人提供）： 本研究的重点是抑郁和焦虑（DEP/ANX）和姑息治疗（PC）的退伍军人住院患者的生活限制性疾病的交叉点。长期目标是改善退伍军人的心理健康和生活质量。拟议的研究将在James J Peters VAMC REAP进行，由Melissa Garrido博士进行，他是一名接受过心理健康服务研究和老年学培训的初级研究员。该提案有两个研究阶段。在第一阶段，目标是量化既存和新诊断的DEP/ANX与结局之间的关系（目标1：ICU入院和再入院;目标2：护理费用）。在这两个目标中，将检验以下内容：a）这些关系通过接受PC调节的假设; B）PC的调节作用将随着接受MHC的增加而增加的假设;和c）PC与PC+MHC对具有不同身体疾病和DEP/ANX组合的退伍军人的相对作用。这些目标将通过对2010-2011财年（FY）退伍军人住院管理数据的二次分析来解决（医疗SAS住院和门诊患者数据集，决策支持系统国家数据提取[DSS NDE]临床文件，生命状态文件和合并的卫生经济学资源中心[HERC]文件）为全国30，000名患有晚期癌症，艾滋病毒/艾滋病，或充血性心力衰竭或慢性阻塞性肺病。目标1将补充200名退伍军人的电子病历，这些退伍军人有资格在2010-2011财年期间在VISN 3中进行住院PC咨询。分析将考虑重复住院和聚类数据，并将解决类似因素可能影响PC和MHC的可能性以及ICU入院和医疗保健费用的事实。 在第二个研究阶段，目标1和目标2的结果将用于制定病例发现干预措施，以确定哪些接受PC的退伍军人在MHC咨询后可能表现出症状负担减轻和ICU使用减少（目标3）。病例发现标准将在行政数据中得到验证，干预措施将得到完善 与临床医生利益相关者的投入。使用非等效比较组中断时间序列设计，将在VISN 3中在设施一级对干预措施进行试点测试。 在CDA阶段的第三年，将制定研究者发起的研究（IIR）提案，以在一项分组随机对照试验中测试病例发现者干预的有效性。从CDA和IIR收集的信息将用于识别那些可以从专业MHC中受益的退伍军人，以及开发和测试针对最需要MHC的退伍军人的干预措施。长期目标是成为独立的VA卫生服务研究员和方法专家，致力于确定护理差距，设计和评估干预措施，以改善重病退伍军人的心理健康。 为了实现职业目标，提出了几项辅导培训活动。导师团队在干预设计和评估，PC，老年精神病学，定量和定性的卫生服务研究方面具有专业知识。培训目标是获得干预设计和实施科学，定性数据分析和纵向数据分析的技能。这些目标将通过课程，阅读，网络和面对面的研讨会，与导师的频繁讨论和会议的混合来实现。每周将与共同主要导师Kenneth Boockvar，MD，MS和Joan Penrod，MA，MSW，PhD举行面对面会议，每月将与次要导师Christopher约翰逊，PhD和冬青Prigerson，PhD举行电话会议。 公共卫生关系： 退伍军人患有限制生命的身体疾病的比例很高。许多患有这些疾病的患者还患有抑郁症和/或焦虑症（DEP/ANX），这与症状恶化，疼痛控制不良，生活质量降低和治疗依从性差有关。在非退伍军人中，DEP/ANX与重症监护室（ICU）入院和再入院的可能性增加以及护理费用增加有关。有一些证据表明，DEP/ANX处理可能会降低成本和不必要的使用。然而，目前尚不清楚姑息治疗（PC）是否足以解决患有生命限制性疾病的退伍军人中的DEP/ANX，以及何时需要精神卫生保健（MHC）（药物和/或心理治疗）。除了作为PC的一部分提供的心理社会支持外，了解疾病特征与MHC需求或受益之间的关系对于VHA的能力非常重要， 优先考虑护理改善工作，并提供以退伍军人为中心的护理。