Palliative Care to Improve Quality of Life in CHF and COPD

 描述（由申请人提供）： 慢性心力衰竭（CHF）和慢性阻塞性肺病（COPD）共同影响高达25%的退伍军人。尽管针对CHF和COPD进行了疾病特异性医疗护理，但患有这两种疾病的退伍军人通常生活质量很差（即，症状加重，功能受损）。这两种疾病的生活质量由于类似的原因而降低，特别是由于呼吸急促和疲劳等显著残留症状以及疼痛和抑郁等其他并发症状的负担。此外，虽然CHF和COPD是住院和死亡的主要原因，但很少有患有这两种疾病的退伍军人参与提前护理计划，即考虑和传达医疗保健价值观和目标的过程。 虽然姑息治疗通常只被认为是在生命的最后，它有很大的潜力，以提高生活质量和提前护理计划的退伍军人在疾病的早期，伴随着正在进行的医疗管理。我们的初步研究表明，以退伍军人为中心的姑息治疗干预在CHF和COPD中取得了早期成功。姑息治疗干预，缓解症状和适应疾病的协作护理（CASA）包括以下组成部分：（1）由护士提供的呼吸困难，疲劳和疼痛的算法指导管理;该算法补充了以姑息治疗和行为治疗为重点的疾病治疗;（2）由社会工作者提供的6次心理社会护理计划，旨在适应疾病和抑郁症;以及（3）让患者和提供者参与预先护理计划。 我们建议进行一项混合有效性和实施研究，以进一步评估CASA干预措施。将使用基于人群的抽样方法入组300名生活质量差且有住院或死亡风险的CHF或COPD退伍军人。主要目的是在两个VA医疗保健系统的随机对照试验（干预与加强常规护理）中测试CASA的有效性。我们将确定CASA干预对以下方面的影响：（a）作为主要结局的生活质量，以及（B）作为次要结局的疾病特异性健康状况、抑郁、症状负担、提前护理计划沟通和记录、急诊科就诊、住院和死亡率。 在本研究的第二个目的中，我们将使用定性和定量相结合的方法来检查干预措施的实施情况。在有效性研究中很少系统地收集关于执行情况的信息，尽管这对于指导未来干预措施的制定以及成功实施和传播姑息治疗和团队干预措施至关重要。从这一目标中获得的信息将为未来的姑息治疗和基于团队的干预措施以及扩大姑息治疗范围的方法提供信息。 这项拟议中的研究意义重大，因为它旨在根据退伍军人的目标和对常见、负担沉重的疾病的偏好，改善生活质量和提供护理。这项研究具有创新性，因为它（1）测试了CHF和COPD（退伍军人死亡的主要原因）姑息治疗的有效性;（2）将姑息治疗和疾病特异性治疗与抑郁症的心理社会治疗相结合，以改善生活质量;（3）利用附属医疗服务提供者的技能（护士，社会工作者）提供基本的姑息治疗，与医生的监督;和（4）使用 一种混合的有效性/实施设计，以增加与运营领导和未来研究的相关性。该研究团队在行为和医疗保健提供临床试验，CHF和COPD以及实施科学方面具有专业知识。

 DESCRIPTION (provided by applicant): Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) together affect up to 25% of Veterans. Despite disease-specific medical care for CHF and COPD, Veterans with either illness are often left with poor quality of life (i.e., burdensome symptoms, impaired function). Quality of life is reduced for similar reasons in both illnesses, particularly from the burden of significant residual symptoms such as shortness of breath and fatigue and other concurrent symptoms such as pain and depression. Furthermore, while CHF and COPD are leading causes of hospitalization and mortality, few Veterans with either illness engage in advance care planning, the process of considering and communicating healthcare values and goals. While palliative care is often thought of only at the end of life, it has great potential t improve quality of life and advance care planning for Veterans earlier in illness, concomitant with ongoing medical management. Our preliminary studies demonstrate early success with a Veteran-centered palliative care intervention in CHF and COPD. The palliative care intervention, Collaborative care to Alleviate Symptoms and Adjust to illness (CASA) consists of the following components: (1) algorithm-guided management of breathlessness, fatigue, and pain, provided by a nurse; the algorithms supplement disease-focused treatments with palliative and behavioral treatments; (2) a 6-session psychosocial care program targeting adjustment to illness and depression, provided by a social worker; and (3) engagement of patients and providers in advance care planning. We propose conducting a hybrid effectiveness and implementation study to further evaluate the CASA intervention. Population-based sampling methods will be used to enroll 300 Veterans with CHF or COPD who have poor quality of life and are at risk for hospitalization or death. The primary aim is to test the effectiveness of CASA in a randomized controlled trial (intervention vs. enhanced usual care) in two VA health care systems. We will determine the effect of the CASA intervention on (a) quality of life as a primary outcome, and (b) disease-specific health status, depression, symptom burden, advance care planning communication and documentation, emergency department visits, hospitalizations, and mortality as secondary outcomes. In a secondary aim in this study, we will use a combination of qualitative and quantitative methods to examine the implementation of the intervention. Information on implementation is rarely collected systematically in effectiveness studies, even though it is critical to guide the development of future interventions and for successful implementation and dissemination of palliative care and team-based interventions. The information gained from this aim will inform future palliative care and team-based interventions as well as ways to expand the reach of palliative care. The proposed study is significant because it aims to improve quality of life and provision of care according to Veterans' goals and preferences in common, burdensome illnesses. The study is innovative because it (1) tests the effectiveness of palliative care in CHF and COPD, leading causes of death among Veterans; (2) combines palliative and disease-specific care for symptoms with psychosocial treatment for depression to improve quality of life; and (3) leverages the skills of affiliate health providers (nurses, social workers) to provide basic palliative care, with physician supervision; and (4) uses an hybrid effectiveness/implementation design to increase the relevance to operations leaders and future research. The research team has expertise in behavioral and health care delivery clinical trials, CHF and COPD, and implementation science.