Defining Optimal Care for Urinary Stone Disease in the Veterans Health Administration

退伍军人健康管理局定义泌尿系结石的最佳护理

• 批准号: 10506323
• 负责人: John Thomas Leppert
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-10-01 至 2025-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10506323
• 关键词: Address; Adoption; American; American College of Physicians; Caring; Chronic Disease; Clinic; Clinical; Clinical Trials; Complex; Data; Diagnosis; Diffuse; Diffusion; Disease; Drug Prescriptions; Economics; Emergency department visit; Event; Expert Opinion; Face; Future; Geographic Locations; Guidelines; Health; Health Care Costs; Healthcare; Healthcare Systems; Hour; Hyperparathyroidism; Injury to Kidney; Lead; Measurement; Measures; Methodology; Methods; Morbidity - disease rate; Nephrology; Operative Surgical Procedures; Outcome; Pain; Patients; Pattern; Pharmaceutical Preparations; Positioning Attribute; Practice Guidelines; Practice Management; Prevention; Prevention Guidelines; Prevention Measures; Prevention strategy; Primary Care; Process Measure; Provider; Quality of Care; Recommendation; Recurrence; Recurrent disease; Research; Secondary Prevention; Surveys; Testing; Time; United States; Urinary Calculi; Urinary tract; Urinary tract infection; Urine; Urology; Variant; Veterans; Veterans Health Administration; Work; care providers; clinical practice; cohort; comparative effectiveness study; design; disorder prevention; disorder risk; effective intervention; effectiveness evaluation; evidence base; evidence based guidelines; experience; implementation barriers; improved; indexing; innovation; medical specialties; prevent; primary care practice; primary care provider; prospective; randomized, clinical trials; screening; treatment strategy; urologic

Background: Urinary stone disease (USD) imposes a major economic and health burden on the United States and the Veterans Health Administration (VHA). Current barriers to delivering optimal health care to patients with USD include the dearth of evidence-based process measures and treatments and the complexity of secondary prevention measures for USD. Significance/Impact: Current guidelines for best practice management of USD are largely based on clinical principles or expert opinion. The relative lack of evidence-based guidelines may lead to suboptimal care and drive unwanted practice pattern variability of quality of care for USD. The proposed research will address the following VHA/ORD priorities: Primary care practice and management of complex chronic diseases (such as recurrent USD) and quality measurement of USD prevention. Innovation: The proposed research will determine which guideline-recommended strategies are effective for secondary prevention of USD. Randomized clinical trials are not yet on the horizon, and so our findings hold the promise of rapidly expanding the evidence base for optimal care of USD and shift the clinical practice paradigm for USD towards primary care providers so that more Veterans with USD can receive effective stone prevention. Specific Aims: We propose the following specific aims: 1) Determine which prevention measures are associated with lower rates of USD recurrence in the VHA; 2) Evaluate how VHA providers are currently implementing prevention measures for USD; and 3) Identify current barriers to implementing effective prevention measures for USD in the VHA. We hypothesize the following: 1) prevention measures such as screening for primary hyperparathyroidism, 24- hour urine testing, and prescription of stone-related medications are associated with longer periods of time to recurrent USD and/or fewer stone events; 2) primary care providers are less likely than specialty providers to implement prevention measures for USD; and 3) each provider type face unique barriers that reduce utilization of effective stone prevention measures. Methodology: Aim 1 will identify a national cohort of Veterans with incident or recurrent USD between 2010 and 2016 and use methods that mimic randomized clinical trials to identify which guideline-recommended measures lead to longer times to a second USD event or fewer USD events. Aim 2 will examine the proportion of patients who receive care from primary care, nephrology, and urology providers following their index stone event and identify which providers are more or less likely to implement each prevention measure. Aim 3 will conduct national surveys with primary care, nephrology, and urology providers affiliated with the VHA to identify barriers to implementation of effective stone prevention measures. Next Steps/Implementation: The VHA is ideally positioned to support comparative effectiveness studies to determine which best practice guidelines are most effective at reducing USD recurrence. The proposed research will define more clearly best practice management of USD, evaluate how VHA providers are currently implementing prevention measures, and identify barriers that obstruct uniform adoption of best practice management of USD across the VHA. We anticipate that our findings will inform the design of prospective clinical trials (where feasible) and facilitate diffusion of best USD care practices within and beyond the VHA.

背景：尿路结石病 (USD) 给人们带来了重大的经济和健康负担 美国和退伍军人健康管理局 (VHA)。目前的交付障碍 USD 患者的最佳医疗保健包括缺乏循证流程措施 USD 的治疗和二级预防措施的复杂性。 意义/影响：当前美元最佳实践管理指南主要是 基于临床原则或专家意见。相对缺乏循证指南 可能会导致护理质量不佳并导致护理质量出现不必要的实践模式变异 美元。拟议的研究将解决以下 VHA/ORD 优先事项： 初级保健 复杂慢性疾病（如复发性美元）的实践和管理以及质量 美元预防措施。 创新：拟议的研究将确定指南推荐的策略 对USD的二级预防有效。尚未进行随机临床试验 因此，我们的研究结果有望迅速扩大证据基础 USD 的最佳护理并将 USD 的临床实践范式转向初级护理 以便更多拥有美元的退伍军人能够获得有效的结石预防。 具体目标：我们提出以下具体目标： 1) 确定采取何种预防措施 措施与降低 VHA 中 USD 复发率相关； 2) 评估VHA如何 供应商目前正在对美元实施预防措施； 3) 识别当前 在 VHA 中实施有效美元预防措施的障碍。我们假设 以下：1）预防措施，例如筛查原发性甲状旁腺功能亢进症，24- 小时尿液检测和结石相关药物处方与更长的时间有关 经常发生美元和/或更少石头事件的时间段； 2）初级保健提供者较少 比专业供应商更有可能对美元实施预防措施； 3) 每个提供商 类型面临独特的障碍，减少了有效结石预防措施的利用。 方法：目标 1 将确定全国范围内患有意外或复发性 USD 的退伍军人群体 2010 年至 2016 年间，使用模拟随机临床试验的方法来确定哪些 指南建议的措施会导致第二次美元事件的时间更长或美元更少 事件。目标 2 将检查接受初级保健护理的患者比例， 肾脏科和泌尿科提供者跟踪他们的指数结石事件并确定哪些 提供者或多或少有可能实施每项预防措施。目标3将进行 对 VHA 附属的初级保健、肾脏病学和泌尿科提供者进行的全国调查 找出实施有效结石预防措施的障碍。 后续步骤/实施：VHA 非常适合支持比较 有效性研究，以确定哪些最佳实践指南最有效地减少 美元复发。拟议的研究将更清晰地定义最佳实践管理 USD，评估 VHA 提供商目前如何实施预防措施，以及 确定阻碍全球统一采用美元最佳实践管理的障碍 维哈。我们预计我们的研究结果将为前瞻性临床试验的设计提供信息（其中 可行）并促进最佳美元护理实践在 VHA 内外的传播。