Optimizing Specialty Care Access for Veterans with End-Stage Organ Diseases

优化患有终末期器官疾病的退伍军人的特殊护理机会

• 批准号: 10746990
• 负责人: Megan Adkins Adams
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-10-01 至 2027-09-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10746990
• 关键词: Address; Affect; Attitude; Automobile Driving; Black race; Caring; Chronic Disease; Chronic Kidney Failure; Cirrhosis; Clinic; Clinical; Clinical Management; Complex; Data; Development; Disease; Disease Management; Eligibility Determination; Enrollment; Ensure; Equity; Ethnic Origin; Evaluation; Female; Gastroenterologist; Gastroenterology; Gender; Goals; Grant; Health Services Accessibility; Health system; High Prevalence; Inequity; Inpatients; Interview; Investigation; Kidney; Kidney Diseases; Knowledge; Leadership; Life; Liver; Liver diseases; Methods; Mission; Nephrology; Organ; Outcome; Outpatients; Pathway interactions; Patients; Perception; Policies; Predisposition; Process; Provider; Quality of Care; Recommendation; Research; Resources; Role; Sampling; Severity of illness; Specialist; Structure; Surveys; System; Telephone; Transplantation; Variant; Veterans; Veterans Health Administration; Waiting Lists; Work; care delivery; care fragmentation; care providers; chronic liver disease; cohort; community setting; design; end stage liver disease; high risk; improved; innovation; medical specialties; multidisciplinary; multilevel analysis; observational cohort study; parity; post-transplant; primary care provider; provider factors; social health determinants; system-level barriers; virtual

Background: Low rates of referral to specialty care among Veterans represent a significant barrier to access and optimal clinical outcomes. This is particularly true for Veterans with end-stage organ diseases (e.g., advanced chronic kidney disease (CKD), decompensated cirrhosis), who are potentially eligible for life-saving transplantation and require specialty care for optimal disease management. Despite the high prevalence of end-stage liver and kidney diseases among Veterans, less than a third of Veterans with advanced CKD and decompensated cirrhosis are referred to a specialist and <5% for transplant evaluation. A comprehensive assessment of patient-, provider- and system-level factors influencing specialty care referral and referral for transplant evaluation is critical to developing targeted strategies and approaches to optimize referral appropriateness as there is a clear association between being seen by a specialist and improved survival. Significance/Impact: Ensuring timely access to high-quality primary and specialty care is a core mission of the Veterans Health Administration (VHA). Factors affecting specialty care referral and referral for transplant evaluation among Veterans with advanced chronic liver and kidney diseases are incompletely characterized. This knowledge is critical to designing effective strategies to enhance referral appropriateness and optimize access. Hence, there is an urgent unmet need to improve our understanding of these complex relationships and the mechanisms by which they affect referral to specialty care and referral for transplant evaluation. Innovation: Most existing work has focused on steps downstream of referral to specialty care and for transplant evaluation, such as completion of transplant evaluation, waitlisting, transplant receipt, and post- transplant outcomes -- thus, barriers to specialty care referral and referral for transplant evaluation remain understudied. This study will comprehensively examine and identify the multi-level factors driving referral to specialty care and referral for transplant evaluation, with the goal of generating best practice recommendations to optimize referral appropriateness and equity. This knowledge is critical to improving referral processes/pathways, enhancing Veteran outcomes, and informing policy changes to increase parity in access. Aims: 1) Characterize the multi-level factors associated with specialty referral and referral for transplant evaluation among patients with advanced chronic liver and kidney diseases. 2) Examine patient and provider knowledge, attitudes, and perceived barriers/facilitators of specialty care referral and referral for transplant evaluation. 3) Develop best practice recommendations to optimize referral appropriateness and equity using modified Delphi panels. Project Methods: Aim 1 is a retrospective observational cohort study using multi-level modeling to identify key patient-, provider-, and system-level factors associated with non-referral to specialty care and for transplant evaluation. As part of Aim 1, the impact of social determinants of health on referral to specialty care and for transplant evaluation also will be evaluated. In Aim 2, we will conduct semi-structured qualitative interviews with primary and specialty care providers and patients sampled from 6 VA health systems to explore variation in knowledge, attitudes, and perceived barriers/facilitators of referral to specialty care and for transplant evaluation. In Aim 3, we will use a modified Delphi approach to convene two panels of VA operational leaders and other experts to develop best practice recommendations to maximize referral appropriateness and equity. Implementation/Next Steps: This study will provide critical information regarding key factors impacting specialty care referral and referral for transplant evaluation among vulnerable Veterans with advanced chronic liver and kidney diseases. Products of the grant will provide vital information to VHA leaders on how to enhance referral appropriateness and equity by generating actionable strategies to address key barriers to referral to specialty care and for transplant evaluation.

背景：退伍军人中转诊到专科护理的比率低是获得服务的一个重大障碍 和最佳的临床结果。对于患有终末期器官疾病的退伍军人来说尤其如此（例如， 晚期慢性肾病（CKD）、失代偿性肝硬化），可能符合挽救生命的条件 移植和需要专业护理的最佳疾病管理。尽管高流行率， 退伍军人中的终末期肝脏和肾脏疾病，不到三分之一的退伍军人患有晚期CKD， 失代偿期肝硬化患者转诊至专科医生，<5%进行移植评估。全面 评估影响专科护理转诊和转诊的患者、提供者和系统层面因素， 移植评估对于制定有针对性的策略和方法以优化转诊至关重要 适当性，因为专家的诊断与生存率的提高之间存在明确的联系。 重要性/影响：确保及时获得高质量的初级和专科护理是 退伍军人健康管理局（VHA）。影响专科护理转诊和移植转诊的因素 评估退伍军人与先进的慢性肝脏和肾脏疾病的特点不完全。 这些知识对于设计有效的战略以提高转诊的适当性和优化 access.因此，迫切需要提高我们对这些复杂关系的认识 以及它们影响转诊到专科护理和转诊到移植评估的机制。 创新：大多数现有的工作都集中在转诊到专科护理的下游步骤， 移植评估，如完成移植评估，等待，移植接收，和后， 移植结果--因此，专科护理转诊和移植评估转诊的障碍仍然存在 替补演员本研究将全面考察和识别推动转诊的多层次因素， 专科护理和移植评估转诊，目的是产生最佳实践建议 优化转诊的适当性和公平性。这些知识对于改善转诊至关重要 进程/途径，提高退伍军人的成果，并告知政策变化，以提高平等的机会。 目的：1）描述与专科转诊和移植转诊相关的多层次因素 评估晚期慢性肝肾疾病患者。2)检查患者和提供者 专科护理转诊和移植转诊的知识、态度和感知障碍/促进因素 评价3)制定最佳实践建议，以优化转诊的适当性和公平性， 修改的德尔菲面板。 项目方法：目的1是一项回顾性观察性队列研究，使用多水平模型来确定关键的 与未转诊至专科护理和移植相关的患者、提供者和系统层面因素 评价作为目标1的一部分，健康的社会决定因素对转诊到专科护理和 还将评估移植评估。在目标2中，我们将进行半结构化定性访谈 初级和专科护理提供者和患者从6个VA卫生系统抽样，以探索变化 在知识、态度和转介到专科护理和移植的感知障碍/促进因素方面 评价在目标3中，我们将使用修改后的德尔菲方法召集两个VA运营领导小组 和其他专家制定最佳做法建议，以最大限度地提高转诊的适当性和公平性。 实施/后续步骤：本研究将提供有关影响 在患有晚期慢性病的脆弱退伍军人中进行移植评估的专科护理转诊和转诊 肝脏和肾脏疾病。产品的赠款将提供重要的信息，以VHA领导人如何 通过制定可行的战略来解决主要障碍， 转诊到专科护理和移植评估。