De-Intensifying Unnecessary Medications in VA CLC Residents Nearing End of Life

减少对临近生命终点的 VA CLC 居民不必要的药物治疗

• 批准号: 9894749
• 负责人: Carolyn Timberlake Thorpe
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-05-01 至 2020-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9894749
• 关键词: Address; Admission activity; Adoption; Adult; Advanced Development; Affect; Area; Benefits and Risks; Blood Pressure; Caregivers; Caring; Chronic; Chronic Disease; Clinical Data; Consensus; Coronary Arteriosclerosis; Data; Data Set; Diabetes Mellitus; Disease; Elderly; Emergency Situation; Emergency department visit; Ensure; Equilibrium; Event; Family Caregiver; Geriatrics; Goals; Guidelines; Hospital Departments; Hospitalization; Hypertension; Internal Medicine; Intervention; Interview; Life; Life Expectancy; Link; Lipids; Long-Term Care; Maps; Measurement; Medicare claim; Medication Management; Methods; Nursing Homes; Outcome; Palliative Care; Patient Preferences; Patients; Pattern; Performance; Pharmaceutical Preparations; Phase; Population; Practice Guidelines; Probability; Provider; Quality of Care; Recommendation; Records; Reporting; Research; Research Design; Research Priority; Sampling; Scoring Method; Selection Bias; Structure; Time Study; United States National Institutes of Health; Variant; Veterans; Visit; Weight; advanced dementia; adverse drug reaction; adverse event risk; base; care delivery; care systems; caregiving; community living; disorder risk; editorial; end of life; end of life care; experience; glycemic control; high risk; improved; informal caregiver; insight; multiple chronic conditions; outcome prediction; pharmacy benefit; preference; shared decision making; standard of care; therapy design; therapy development; tool; treatment guidelines; uptake

 DESCRIPTION (provided by applicant): The long-term goal of this research is to improve the quality of care provided to VA Community Living Center (CLC) residents with limited life expectancy (LLE) and/or advanced dementia (AD), through the safe and effective use of medication that is aligned with their goals of care. In the years leading up to the development of AD and other life-limiting conditions, most CLC residents have accumulated multiple chronic conditions requiring medication therapy (e.g., coronary artery disease, hypertension, diabetes). However, practice guidelines developed for general adult populations calling for intense treatment of these conditions may no longer be appropriate for residents with LLE/AD, given reduced potential to live long enough to experience benefits and higher propensity for adverse drug reactions. Several geriatric groups have issued recommendations for intense chronic disease treatments to avoid in patients with LLE/AD, but these recommendations have not been consistently integrated into VA or other disease-specific guidelines and their adoption in CLC practice is unknown. These LLE/AD-specific recommendations are also largely based on expert consensus about hypothesized risks and benefits, rather than direct evidence about actual risks and benefits from rigorously designed studies with LLE/AD patients. The lack of direct and specific evidence about this risk/benefit balance hinders the ability of Veterans, their informal caregivers, and VA providers to make informed, shared decisions that are aligned with Veterans' goals of care. In partnership with the VA Office of Geriatric and Extended Care Services (GEC), VA PROMISE Center (Performance Reporting and Outcomes Measurement to Improve the Standard of care at End-of-Life), VA Pharmacy Benefits Management (PBM), and CLC clinicians, we propose a mixed-methods study to understand variation in and outcomes of intense vs. de-intensified treatment in Veterans admitted to a CLC and develop an intervention toolkit to serve as the basis for quality improvement (QI) efforts. Specific aims are to (1) describe patterns of receipt of intense vs. de-intensified treatment for lipid, blood pressure (BP), and glycemic control in Veterans with LLE/AD after CLC admission; (2) examine effects of intense treatment for lipid, BP, and glycemic control after CLC admission on all-cause negative events and disease-specific hospitalizations and emergency visits in Veterans with LLE/AD; and (3) using semi-structured interviews with providers and family caregivers and an established intervention mapping framework, identify key barriers and facilitators to implementing LLE/AD-specific recommendations and design an intervention toolkit to serve as the basis for QI efforts. For quantitative aims 1-2, we will link Minimum Dataset (MDS) assessments, PBM medication records, VA utilization/clinical data, and Medicare claims to examine variation across CLCs in intense vs. de-intensified treatment; identify patient, caregiver, provider, and facility factors contributing to this variation; and determine effects on all-cause and disease-specific negative events. Our analytic approach involves propensity score methods with inverse probability of treatment weights to address potential selection bias and confounding. Using results from Aim 1 to purposively sample from CLCs with lower proportions of intensely treated residents ("early adopters" of LLE/AD recommendations) and higher proportions of intensely treated residents ("late adopters"), qualitative Aim 3 will involve semi-structured interviews with providers and family caregivers of recently deceased CLC residents. With input from our partners, we will use these data to map key barriers and facilitators to implementing LLE/AD-specific recommendations and develop an intervention toolkit that will serve as a basis for QI efforts. This study addresses the HSR&D Priority Area on Long-Term Care and Caregiving and Strategies 1-3 of the VA Blueprint for Excellence. It will have significant impact by providing VA with critical information and tools needed to optimize QI efforts to facilitate implementation of LLE/AD-specific treatment recommendations and support improved shared decision-making about medications in CLC residents near end-of-life.

 描述（由申请人提供）： 本研究的长期目标是通过安全有效地使用与其护理目标一致的药物，提高为VA社区生活中心（CLC）预期寿命有限（LLE）和/或晚期痴呆症（AD）居民提供的护理质量。在 在AD和其他限制生命的疾病发展的前几年，大多数CLC居民已经积累了多种需要药物治疗的慢性疾病（例如，冠状动脉疾病、高血压、糖尿病）。然而，为一般成年人群制定的要求对这些疾病进行强化治疗的实践指南可能不再适用于LLE/AD患者，因为他们的寿命可能会降低，从而无法获得获益，并且药物不良反应的倾向更高。几个老年组已经发布了强烈的慢性病治疗的建议，以避免在LLE/AD患者，但这些建议并没有一贯整合到VA或其他疾病的具体指南，他们在CLC实践中的采用是未知的。这些LLE/AD特异性建议也主要基于关于假设风险和获益的专家共识，而不是来自严格设计的LLE/AD患者研究的实际风险和获益的直接证据。缺乏关于这种风险/受益平衡的直接和具体证据阻碍了退伍军人、他们的非正式护理人员和VA提供者做出与退伍军人护理目标一致的知情、共享决策的能力。在与老年和延伸护理服务（GEC），VA PROMISE中心VA办公室合作（性能报告和结局测量，以提高临终护理标准），VA药房福利管理（PBM）和CLC临床医生，我们提出了一个混合方法的研究，以了解变化和结果的激烈与去，加强对CLC接纳的退伍军人的治疗，并制定干预工具包，作为质量改进（QI）工作的基础。具体目的是（1）描述CLC入院后LLE/AD退伍军人接受强化与去强化治疗的模式，以控制血脂、血压（BP）和血糖;（2）检查CLC入院后LLE/AD退伍军人接受强化治疗对全因阴性事件和疾病特异性住院和急诊的影响;以及（3）使用与提供者和家庭护理者的半结构化访谈以及已建立的干预映射框架，确定实施LLE/AD特定建议的关键障碍和促进因素，并设计干预工具包作为QI工作的基础。对于定量目标1-2，我们将链接最小数据集（MDS）评估、PBM用药记录、VA利用/临床数据和医疗保险索赔，以检查CLC在强化治疗与去强化治疗中的差异;确定导致这种差异的患者、护理人员、提供者和设施因素;并确定对全因和疾病特异性负面事件的影响。我们的分析方法涉及倾向评分方法与治疗权重的逆概率，以解决潜在的选择偏倚和混淆。使用目标1的结果，有目的地从CLC中抽取样本，其中强化治疗的居民（LLE/AD建议的“早期采用者”）比例较低，强化治疗的居民（“晚期采用者”）比例较高，定性目标3将涉及与最近去世的CLC居民的提供者和家庭照顾者进行半结构化访谈。在我们合作伙伴的投入下，我们将利用这些数据来绘制实施LLE/AD特定建议的关键障碍和促进因素，并开发一个干预工具包，作为QI工作的基础。本研究涉及HSR&D长期护理和护理的优先领域以及VA卓越蓝图的战略1-3。它将通过为VA提供优化QI工作所需的关键信息和工具来产生重大影响，以促进实施LLE/AD特定治疗建议，并支持改善CLC居民接近生命末期的药物共享决策。