Quality of Care for Hepatitis C in Veterans Who Are Homeless

无家可归的退伍军人的丙型肝炎护理质量

• 批准号: 10027248
• 负责人: Donald Keith McInnes
• 金额: --
• 依托单位: EDITH NOURSE ROGERS MEMORIAL VETERANS HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-07-01 至 2019-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10027248
• 关键词: Achievement; Alcohol or Other Drugs use; Antiviral Therapy; Blood; Caring; Centers for Disease Control and Prevention (U.S.); Cessation of life; Characteristics; Cirrhosis; Clinical; Cohort Analysis; Continuity of Patient Care; Data; Data Collection; Databases; Decision Making; Diagnosis; Direct Costs; Disease; Drug Costs; Emergency Care; Ensure; Goals; Health; Healthcare; Healthcare Systems; Hepatitis; Hepatitis C; Hepatitis C virus; High Prevalence; Homeless persons; Homelessness; Housing; Human; Individual; Intervention; Interview; Learning; Malignant neoplasm of liver; Measures; Medical; Medical center; Mental Health; Methods; Modeling; Needle Sharing; Pathway interactions; Patients; Pattern; Performance; Persons; Pharmaceutical Preparations; Population; Post-Traumatic Stress Disorders; Prevalence; Primary Health Care; Primary carcinoma of the liver cells; Process; Public Health; Quality of Care; Research; Retrospective cohort; Risk; Self Management; Services; Site; Site Visit; Social support; Specialist; Substance Use Disorder; System; Testing; Time; Time Study; Veterans; Viral; Visit; Vulnerable Populations; Work; base; burden of illness; comorbidity; cost; demographics; experience; health administration; health care availability; implementation research; improved; injection drug use; inpatient service; lens; liver injury; medical specialties; mortality; response; study population; supported housing; therapy design; therapy development

 DESCRIPTION (provided by applicant): Background: Despite initiatives to end Veteran homelessness, over 137,000 Veterans were homeless at some point during 2013. Homeless persons, compared to housed, are sicker and have mortality rates 5-9 times higher. Healthcare for homeless Veterans is characterized by discontinuities in care, difficulty adhering to treatment, and frequent use of emergency and inpatient care. Hepatitis C virus (HCV) is an exemplar condition for understanding deficiencies in health systems' care for homeless persons because of the high prevalence in this population (over 20%) and the need for continuity of care in both primary and specialty care. HCV is the most common blood borne disease in the US with 3.2 million persons infected. It causes liver damage, hepatocellular cancer, and death. Quality HCV care involves sequential steps from identification, to linkage to a specialist, treatment initiation and treatment completion. This pathway has been formalized in a model called the HCV Care Continuum. Among those infected with HCV, however, only 50% have been diagnosed, 38% referred to HCV specialty care, 11% put on anti-viral therapy, and 6% achieved sustained viral response (SVR; i.e. cure). Data suggest the percentages for homeless persons are lower. Objectives: The goal of this study is to provide the first system-wide analysis of health care for homeless Veterans, through the lens of HCV care; and then to develop an intervention to spread best practices for homeless HCV care throughout VHA. The aims are: Aim 1: Describe how homeless HCV+ Veterans are distributed among VA medical centers; Aim 2: Evaluate quality of care for homeless and non-homeless Veterans as measured by progress along the HCV Care Continuum and the relationship of quality to patient, facility, and housing characteristics. Aim 3: Develop an intervention to improve HCV care for homeless Veterans, and submit a proposal to pilot test the intervention. Methods: This is a 3-year mixed-methods study combining retrospective cohort analysis of VA databases with qualitative data collection. For quantitative analyses the study population consists of >6.5 million Veterans in VHA care between FY09-14. Two subsets are also analyzed: all homeless Veterans (around 267,000), and HCV+ Veterans who are homeless (around 36,000). Adjusted models will indicate whether degree of homelessness (long-term supportive housing, at-risk of homelessness, or currently homeless) and individual modifiable factors (e.g. PTSD, substance use) and facility characteristics have differential effects on achievement of Continuum measures. In Aim 3, based on the analyses of the 36,000 homeless HCV Veterans in VHA care, we will identify 3 higher and 3 lower performing facilities (on the Care Continuum) based on risk adjusted profiling. We will make site visits and interview stakeholders (e.g. clinicians, staff, Veterans) to learn about best practices, as well as challenge and barriers to providing HCV care to homeless Veterans in their facilities. Findings from qualitative and quantitative data will be incorporated into the design of an intervention. Anticipated impact on Veterans' healthcare: VHA supports efforts to end Veteran homelessness by 2015. Yet it has never assessed system-wide performance to ensure that healthcare for homeless Veterans is accessible, continuous, and engages Veterans in self-management of medical conditions. Such an analysis, using HCV as an exemplar condition, will be conducted in this study. It will identify strengths and weaknesses of VHA hepatitis care for homeless Veterans, pinpointing where breakdowns occur in the treatment pathway. It will also identify several high- and low-performing VA medical centers based on percentage of their HCV+ Veterans who initiated treatment. These sites will be visited to identify best practices and strategies for overcoming barriers. An intervention will be developed to spread best practices through implementation research. These studies will lead to improved care for homeless and non-homeless HCV+ Veterans alike.

 描述(由申请人提供)： 背景：尽管采取了结束退伍军人无家可归的举措，但在2013年的某个时候，仍有超过13.7万名退伍军人无家可归。无家可归的人与有住房的人相比，病情更重，死亡率高出5-9倍。无家可归退伍军人的医疗保健的特点是护理中断，难以坚持治疗，经常使用急救和住院护理。丙型肝炎病毒(丙型肝炎病毒)是了解卫生系统对无家可归者的护理不足的一个典型条件，因为这一人群的感染率很高(超过20%)，并且需要在初级和专科护理中持续护理。丙型肝炎病毒是美国最常见的血液传播疾病，有320万人感染。它会导致肝脏损伤、肝细胞癌和死亡。高质量的丙型肝炎病毒护理包括从识别、到专家联系、治疗开始和治疗完成的顺序步骤。这一途径已经在一个名为丙型肝炎病毒护理连续体的模型中被形式化。然而，在感染丙型肝炎病毒的人中，只有50%得到了诊断，38%转诊到丙型肝炎病毒专科护理，11%接受了抗病毒治疗，6%实现了持续病毒应答(SVR；即治愈)。数据显示，无家可归者的比例更低。目的：本研究的目的是通过丙型肝炎病毒护理的视角，首次对无家可归的退伍军人进行系统范围的卫生保健分析；然后开发一种干预措施，将无家可归的丙型肝炎病毒护理的最佳实践推广到VHA。目标1：描述无家可归的丙型肝炎病毒+退伍军人在退伍军人管理局医疗中心的分布情况；目标2：评估无家可归和非无家可归退伍军人的护理质量，通过丙型肝炎病毒护理连续体的进展以及质量与患者、设施和住房特征的关系来衡量。目标3：制定一项干预措施，以改善对无家可归退伍军人的丙型肝炎病毒护理，并提交一份提案，对该干预措施进行试点测试。方法：这是一项为期3年的混合方法研究，结合了对退伍军人事务部数据库的回顾队列分析和定性数据收集。为了进行定量分析，研究人群包括2009-2014财年接受VHA护理的650万退伍军人。还分析了两个子集：所有无家可归的退伍军人(约267,000人)，以及无家可归的丙型肝炎病毒+退伍军人(约36,000人)。调整后的模型将表明无家可归的程度(长期支持性住房、无家可归的风险或目前无家可归)和个人可修改因素(例如创伤后应激障碍、药物使用)和设施特征是否对连续措施的实现有不同的影响。在目标3中，基于对VHA护理中36,000名无家可归的丙型肝炎病毒退伍军人的分析，我们将根据风险调整概况确定3个较高和3个表现较差的设施(在护理连续体上)。我们将进行实地考察和采访利益相关者(例如临床医生、工作人员、退伍军人)，以了解最佳实践，以及在设施中向无家可归的退伍军人提供丙型肝炎病毒护理的挑战和障碍。来自定性和定量数据的结果将被纳入干预设计。对退伍军人医疗保健的预期影响：VHA支持在2015年前结束退伍军人无家可归的努力。然而，它从未评估全系统的业绩，以确保无家可归的退伍军人的医疗保健是可获得的、持续的，并使退伍军人参与医疗条件的自我管理。在这项研究中，将以丙型肝炎病毒为例进行这种分析。它将确定为无家可归的退伍军人提供VHA肝炎护理的优势和劣势，准确地指出治疗路径中发生故障的地方。它还将根据开始治疗的丙型肝炎病毒阳性退伍军人的百分比来确定几个高绩效和低绩效的退伍军人医疗中心。将访问这些地点，以确定克服障碍的最佳做法和战略。将制定干预措施，通过实施研究传播最佳做法。这些研究将改善对无家可归和非无家可归的丙型肝炎病毒+退伍军人的护理。