Impact of COVID-era Disrupted Care on Disparities in Outcomes among Veterans with Kidney Failure

新冠病毒时代护理中断对肾功能衰竭退伍军人结果差异的影响

• 批准号: 10755601
• 负责人: AMAL N. TRIVEDI
• 金额: --
• 依托单位: DURHAM VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-08-01 至 2024-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10755601
• 关键词: Acute; Address; Affect; Ambulatory Care; Area; Authorization documentation; Blood Vessels; COVID-19; COVID-19 impact; COVID-19 morbidity; COVID-19 pandemic; COVID-19 vaccination; Caring; Chronic; Clinic; Clinical; Collaborations; Communities; Community Financing; Community Healthcare; Comparative Study; Complex; Computerized Medical Record; Critical Care; Data; Dedications; Diagnostic; Dialysis patients; Dialysis procedure; Disasters; Disease Management; Disparity; Economically Deprived Population; Emergency Situation; End stage renal failure; Enrollment; Evaluation; Frequencies; Future; Health; Health Personnel; Health Services Accessibility; Health Services Administration; Healthcare; Immunocompromised Host; Improve Access; Integrated Health Care Systems; Intervention; Kidney; Kidney Diseases; Kidney Failure; Life; Longitudinal cohort study; Maintenance; Managed Care; Medicare; Methodology; Morbidity - disease rate; Nature; Neighborhoods; Outcome; Patient Transfer; Patients; Patterns of Care; Phase; Policies; Predisposition; Primary Care; Private Sector; Procedures; Process; Provider; Public Health; Recovery; Renal function; Research; Resources; Risk Factors; SARS-CoV-2 exposure; SARS-CoV-2 infection; Services; Shapes; Social Work; Socioeconomic Status; Structure; Survival Rate; System; Time; Vaccines; Veterans; Veterans Health Administration; Work; access disparities; authority; care delivery; care fragmentation; care providers; care systems; cohort; community setting; coronavirus disease; ethnic disparity; ethnic minority; experience; health equity; improved; medical specialties; military veteran; mortality; multiple chronic conditions; outcome disparities; pandemic disease; pandemic impact; participant enrollment; patient population; programs; racial disparity; racial minority; social; social health determinants; socioeconomic disadvantage; socioeconomic disparity; tertiary care; treatment adherence

Background: The COVID-19 pandemic significantly disrupted care delivery that limited access to providers, acute and timely non-acute evaluation, and clinical intervention. Dialysis patients with kidney failure are particularly vulnerable to COVID-19 infection, COVID-19 related morbidity and mortality because they commonly have multiple chronic conditions, typically require thrice weekly life-sustaining dialysis treatment in close- quartered clinic settings, are already prone to fragmented care, and especially susceptible to disrupted care. The COVID-19 pandemic presents fundamental threats to dialysis patients, and there is an urgent need to examine the impact of disrupted care for this vulnerable and uniquely healthcare reliant population of patients. Over 16,000 of enrolled Veterans receive chronic dialysis through Veterans Health Administration (VA) Kidney Program’s VA and VA Community Care providers. VA Community Care improves access to life- sustaining dialysis services for 80% of Veterans with kidney failure with limited access to the VHA’s 70 dialysis units. In prior work, we found lower 2-year mortality among Veterans receiving dialysis exclusively in VA compared to those receiving dialysis in non-VA settings, consistent with VA and non-VA comparative studies in other clinical contexts. These differences may be due to more comprehensive integrated services (e.g., co- located primary and tertiary care services, care management, social work, national electronic medical record) in VA, compared with the more fragmented and siloed dialysis care in private sector community settings. Significance: Pandemic-related disruptions may disproportionately affect Veterans with serious conditions and social risk factors like those with kidney failure and the nature and impact of pandemic-related disruptions may differ in VA and non-VA systems. However, rigorous comparisons of COVID-related care disruptions and outcomes between Veterans receiving healthcare in VA and non-VA settings are lacking. Specific Aims: Building on our team’s research expertise, this study will: 1) Quantify the impact of COVID-19 on 1a) disrupted care for prevalent patients and 1b) deferred care for incident patients in a national cohort of Veterans with ESKD and compare the extent of these impacts between VA- financed dialysis care in VA and VA Community Care settings from 2018-2022. 2) Compare patient-level outcomes and racial and socioeconomic disparities in outcomes in VA and non-VA dialysis settings before and during the COVID pandemic time periods. Methodology: We will conduct a longitudinal cohort study of all VA-enrolled patients with end-stage kidney disease receiving VA-financed dialysis care between 2018 and 2022, to observe care patterns before the pre- COVID phase (Jan 2018-Feb 2020), the acute COVID phase defined as the first case of COVID until authorization of the vaccine (Mar 2020-Dec 2020) and the recovery phase when COVID-19 vaccination was available (Jan 2021-Dec 2022). Study data will be derived from linkages of VA and Medicare administrative data with community-level national COVID-19 tracking and neighborhood socioeconomic status data to assess the impacts of pandemic-related disruptions in care on disparities in outcomes among Veterans receiving dialysis in VA and non-VA settings. Next Steps/Implementation: This research is directly responsive to the COVID RFA HX-21-025: Pandemic related disrupted and deferred care and three VA HSR&D priority areas (Access to Care, Complex Disease Management, Social Determinants of Health). The study team is conducting this work partnership with the VHA National Program for Kidney Disease to ensure that our work is poised to shape evolving VA policy around provision of community care and to improve care for Veterans during the COVID-19 pandemic, recovery, and future public health crises. Results will inform how VA manages its Veterans in disaster scenarios, particularly with provider partners in VA community care, for whom the VA relies on for reliable and accessible dialysis care.

背景：2019冠状病毒病大流行严重扰乱了医疗服务，限制了获得医疗服务的机会， 急性和及时的非急性评估以及临床干预。肾衰竭的透析患者 特别容易受到COVID-19感染，COVID-19相关的发病率和死亡率，因为它们通常 有多种慢性疾病，通常需要每周三次的生命维持透析治疗， 四分之一的诊所设置，已经倾向于分散的护理，特别是容易受到中断的护理。的 COVID-19大流行对透析患者构成了根本性威胁，迫切需要研究 中断护理对这一脆弱和独特的依赖医疗保健的患者群体的影响。 超过16，000名注册的退伍军人通过退伍军人健康管理局（VA）接受慢性透析 肾脏计划的VA和VA社区护理提供者。VA社区护理改善了生活的可及性- 为80%的肾衰竭退伍军人提供持续的透析服务，这些退伍军人只能有限地获得VHA的70次透析 单位在之前的工作中，我们发现仅在VA接受透析的退伍军人的2年死亡率较低 与在非VA环境中接受透析的患者相比，与VA和非VA比较研究一致， 其他临床背景。这些差异可能是由于更全面的综合服务（例如，共 位于初级和三级保健服务，护理管理，社会工作，国家电子病历）， VA，与私营部门社区环境中更分散和孤立的透析护理相比。 重要性：与流行病相关的中断可能不成比例地影响病情严重的退伍军人， 社会风险因素，如肾衰竭患者以及与流行病相关的破坏的性质和影响， 在VA和非VA系统中不同。然而，严格比较COVID相关的护理中断和 缺乏在VA和非VA环境中接受医疗保健的退伍军人之间的结果。 具体目标：基于我们团队的研究专长，本研究将： 1)量化COVID-19对1a）对流行病患者的中断护理和1b）对事件的延迟护理的影响 患者在一个国家队列的退伍军人ESKD，并比较这些影响的程度之间VA- 从2018年到2022年，在VA和VA社区护理环境中资助透析护理。 2)比较VA和非VA患者水平的结局以及结局的种族和社会经济差异 在COVID大流行时期之前和期间的透析设置。 方法：我们将对所有VA入组的终末期肾病患者进行纵向队列研究。 在2018年至2022年期间接受VA资助的透析护理的疾病，以观察预 COVID阶段（2018年1月至2020年2月），急性COVID阶段定义为第一例COVID病例，直至 疫苗授权（2020年3月至2020年12月）和COVID-19疫苗接种的恢复阶段 可用（2021年1月至2022年12月）。研究数据将来自VA和Medicare管理数据的链接 社区层面的全国COVID-19跟踪和社区社会经济状况数据，以评估 流行病相关的护理中断对接受透析的退伍军人结果差异的影响 VA和非VA设置。 后续步骤/实施：本研究直接响应COVID RFA HX-21-025：大流行 相关中断和延迟护理以及VA HSR&D的三个优先领域（获得护理、复杂疾病 健康的社会决定因素）。研究小组正在与VHA开展这项工作伙伴关系 国家肾脏疾病计划，以确保我们的工作准备塑造不断发展的VA政策， 在COVID-19大流行期间，提供社区护理并改善对退伍军人的护理， 未来的公共卫生危机。结果将告知VA如何在灾难情况下管理其退伍军人，特别是 与退伍军人事务部社区护理的提供者合作伙伴合作，退伍军人事务部依赖他们提供可靠和可获得的透析护理。