Improving Implementation of Outpatient Goals of Care Conversations for Veteranswith Serious Illness

背景：VA实施了生命维持治疗决策倡议（LSTDI），以引出，记录， 并荣誉患有严重疾病的退伍军人的价值观、目标和偏好。The National Academy of 医学建议，患者和家属更喜欢护理对话的目标（ LSTDI）发生时，他们不是急性病在门诊设置。然而，在全国范围内，大多数目标 的护理谈话发生在住院病人接近死亡的情况下，只有39%发生在门诊病人。 意义/影响：本研究将确定改善门诊患者LSTDI实施的策略 设置.这对退伍军人来说意义重大，因为它确保他们能够表达自己的目标和生活偏好 持续治疗并让他们得到尊重。VA秘书的两个优先事项得到解决：（1）目标是 提供关于维持生命治疗的“明确信息，以做出明智的决定”，以及（2） 退伍军人得到“照顾和支持......强调他们的福祉和独立性， 生命之旅”该提案通过以下方式解决了增加VA研究的现实影响的研发目标 了解如何改善国家VA政策的实施。与HSR&D优先事项保持一致， 提案中所述。 创新：该提案采用了创新的研究设计，即序贯多重分配随机试验 （SMART）。将面向患者和面向提供者的实施战略相结合，被认为很重要 在我们的初步研究中，也是创新的。最后，我们采用基于人口的方法来了解 在患有严重非癌症疾病的重病退伍军人中实施护理对话目标 包括心力衰竭和慢性肺、肾和肾脏疾病。 具体目标。目标1.在三个VA卫生系统中使用临床医生级SMART来确定有效性 临床医生和患者实施策略，以提高记录的护理目标的发生率 有严重医疗疾病的退伍军人的谈话。目标2a。确定实施顺序 战略，导致整体最大的增加，在文件的目标护理对话。目标2b （探索性）。确定患者和临床医生的特征，这些特征会改变实施顺序的效果 关于记录护理对话目标的战略。目标3.了解临床医生和患者 实施策略的成功或失败，使用混合方法评估，涉及临床医生，领导者， 患者和护理人员。 方法：研究地点包括VA东部科罗拉多、大洛杉矶和帕洛阿尔托卫生保健中心 系统.我们将针对退伍军人中护理对话目标率较低的临床医生， 住院或死亡风险前10%的疾病。我们将首先测试较少的资源密集型 策略，随后将PACT团队随机分配到持续低对话率的 增加当前策略的强度或使用当前策略的时间。数据将从 VA公司数据仓库（目标1和2）以及患者、护理人员和临床医生访谈或调查 (Aims第2和第3段）。将使用定性和定量方法分析数据。 下一步/实施：将与我们的业务伙伴合作传播研究结果 （国家卫生保健、初级保健、姑息治疗伦理中心）。我们的合作伙伴可以实施政策 根据研究结果，增加早期，门诊实施LSTDI。

Background: VA implemented the Life Sustaining Treatment Decisions Initiative (LSTDI) to elicit, document, and honor the values, goals, and preferences of Veterans with serious illness. The National Academy of Medicine recommends, and patients and families prefer goals of care conversations (the foundation of the LSTDI) occur when they are not acutely ill in the outpatient setting. However, across VA nationally, most goals of care conversations occur in the inpatient setting close to death; only 39% occur in the outpatient setting. Significance/Impact: This study will identify strategies to improve LSTDI implementation in the outpatient setting. This is significant to Veterans because it ensures they can express their goals and preferences for life sustaining treatments and have them honored. Two VA Secretary priorities are addressed: (1) the goal to provide “clear information to make informed decisions” about life-sustaining treatments, and (2) the goal for Veterans to receive “care and support… that emphasizes their well-being and independence throughout their life journey.” This proposal addresses the R&D goal to increase real-world impact of VA research by understanding how to improve implementation of a national VA policy. Alignment with HSR&D priorities is described in the proposal. Innovation: The proposal uses an innovative study design, a sequential multiple assignment randomized trial (SMART). The combination of patient-facing and provider-facing implementation strategies, deemed important in our preliminary studies, is also innovative. Finally, we take a population-based approach to understand the implementation of goals of care conversations in seriously ill Veterans with serious non-cancer illnesses including heart failure and chronic pulmonary, renal, and kidney diseases. Specific Aims. Aim 1. Use a clinician-level SMART in three VA health systems to determine the effectiveness of clinician and patient implementation strategies to improve the occurrence of documented goals of care conversations in Veterans with serious medical illness. Aim 2a. Identify the sequence of implementation strategies that leads to the overall greatest increase in documentation of goals of care conversations. Aim 2b (exploratory). Identify patient and clinician characteristics that modify the effect of sequences of implementation strategies on documentation of goals of care conversations. Aim 3. Understand clinician and patient implementation strategy success or failure using a mixed method evaluation involving clinicians, leaders, patients, and caregivers. Methodology: Study sites include the VA Eastern Colorado, Greater Los Angeles, and Palo Alto Health Care Systems. We will target clinicians with low rates of goals of care conversations among Veterans with medical illness in the top 10th percentile of risk of hospitalization or death. We will first test less resource intensive strategies, and subsequently randomize PACT teams with continued low rates of conversations to either an increased intensity of the current strategy or more time with the current strategy. Data will be collected from the VA Corporate Data Warehouse (Aims 1 and 2) and patient, caregiver, and clinician interviews or surveys (Aims 2 and 3). Data will be analyzed using qualitative and quantitative methods. Next Steps/Implementation: Study findings will be disseminated in collaboration with our operations partners (National Center for Ethics in Health Care, Primary Care, Palliative Care). Our partners can implement policies based on study findings to increase early, outpatient implementation of the LSTDI.