Impact of Mental Illness on Veterans' Palliative Care Access and Outcomes

描述(由申请人提供)： 这项研究的重点是抑郁和焦虑(DEP/ANX)和姑息护理(PC)的交集，为患有限制生命的疾病的退伍军人住院患者。长期目标是改善退伍军人的心理健康和生活质量。这项拟议的研究将在詹姆斯·J·彼得斯VAMC REAP进行，由梅丽莎·加里多博士进行，她是一名初级研究员，接受过心理健康服务研究和老年学方面的培训。这项提议有两个研究阶段。在第一阶段，目标是量化先前存在的和新诊断的DEP/ANX与结果之间的关系的大小(目标1：ICU入院和再入院；目标2：护理费用)。在这两个目标中，将检验以下假设：a)这些关系因接受PC而被调节的假设；b)PC的调节作用将随着接收MHC的增加而增加的假设；以及c)PC与PC+MHC对具有不同身体疾病和DEP/ANX组合的退伍军人的相对影响。这些目标将通过对2010-2011财年(FY)退伍军人住院管理数据(医疗SAS住院和门诊数据集、决策支持系统国家数据摘录[DSS NDE]临床文件、生命状况文件和综合卫生经济资源中心[HERC]文件)的二次分析来实现，这些数据涉及全国30,000名晚期癌症、艾滋病毒/艾滋病、充血性心力衰竭或慢性阻塞性肺疾病的住院退伍军人。AIM 1将补充200名退伍军人的电子病历，这些退伍军人有资格在2010-2011财年期间在VISN 3接受住院PC会诊。分析将解释重复住院和聚集数据，并将解决这样一个事实，即类似因素可能影响PC和MHC的可能性以及ICU入院和医疗费用。在第二研究阶段，目标1和目标2的结果将被用于制定病例发现干预措施，以确定哪些接受PC的退伍军人在接受MHC会诊后症状负担和ICU使用减少(目标3)。病例发现者标准将在行政数据中得到验证，干预措施将得到完善 来自临床医生利益相关者的意见。使用非等价对照组中断时间序列设计，干预措施将在VISN 3的设施水平进行试点测试。在CDA期间的第三年，将制定一项调查者发起研究(IIR)建议，以在分组随机对照试验中测试病例发现者干预的有效性。从CDA和IIR收集的信息将用于确定哪些退伍军人可以从专业MHC中受益，以及开发和测试针对最需要MHC的退伍军人的干预措施。长期目标是成为一名独立的退伍军人健康服务研究员和方法专家，致力于确定护理和设计方面的差距，并评估改善重病退伍军人心理健康的干预措施。为了实现职业目标，已经提出了几项有指导的培训活动。导师团队在干预设计和评估、PC、老年精神病学以及定量和定性卫生服务研究方面拥有专业知识。培训目标是获得干预设计和实施科学、定性数据分析和纵向数据分析方面的技能。这些目标将通过课程、阅读资料、网络和面对面研讨会、与导师的频繁讨论和会议来实现。每周将与联合初选导师Kenneth Boockvar，MD，MS和Joan Penrod，MA，MSW，PhD举行面对面会议，每月与次要导师Christopher Johnson博士和Holly Prigerson博士进行电话交谈。

DESCRIPTION (provided by applicant): This study focuses on the intersection of depression and anxiety (DEP/ANX) and palliative care (PC) for Veteran inpatients with life-limiting illnesses. The long-term goal is to improve Veteran mental health and quality of life. The proposed research would be carried out at the James J Peters VAMC REAP, by Melissa Garrido, PhD, a junior investigator with training in mental health services research and gerontology. There are two research phases of this proposal. In the first phase, the goals are to quantify the magnitude of the relationship between pre-existing and newly diagnosed DEP/ANX and outcomes (Aim 1: ICU admissions and readmissions; Aim 2: costs of care). In both aims, the following will be tested: a) The hypothesis that these relationships are moderated by receipt of PC; b) The hypothesis that the moderating effect of PC will be increased with the addition of receipt of MHC; and c) The relative effect of PC versus PC+MHC for Veterans with different combinations of physical illnesses and DEP/ANX. These aims will be addressed via secondary analysis of Fiscal Years (FY) 2010-2011 Veteran inpatient administrative data (Medical SAS Inpatient and Outpatient Datasets, Decision Support System National Data Extract [DSS NDE] Clinical Files, Vital Status Files, and combined Health Economics Resource Center [HERC] files) for 30,000 inpatient Veterans across the nation with advanced cancer, HIV/AIDS, or congestive heart failure or chronic obstructive pulmonary disease. Aim 1 will be supplemented with electronic medical records of 200 Veterans who are eligible for an inpatient PC consultation in VISN 3 during FYs 2010-2011. Analyses will account for repeated hospitalizations and clustered data, and will address the fact that similar factors may influence both likelihood of PC and MHC as well as ICU admissions and health care costs. In the second research phase, the results from Aim 1 and Aim 2 will be used to inform the development of a case-finding intervention that identifies which Veterans receiving PC may exhibit reduced symptom burden and reduced ICU use following a MHC consult (Aim 3). The case-finder criteria will be validated in administrative data, and the intervention will be refined with input from clinician stakeholders. Using a non-equivalent comparison group interrupted time-series design, the intervention will be pilot tested at the facility level in VISN 3. In the hird year of the CDA period, an Investigator Initiated Research (IIR) proposal will be developed to test the efficacy of the case-finder intervention in a clustered randomized controlled trial. The information gathered from the CDA and IIR will be used to identify those Veterans who could benefit from specialty MHC as well as to develop and test an intervention to target MHC to Veterans who need it most. The long-term goal is to be an independent VA health services researcher and methods expert working to identify gaps in care and design and evaluate interventions to improve the mental health of seriously ill Veterans. To reach the career goals, several mentored training activities have been proposed. The mentorship team has expertise in intervention design and evaluation, PC, geriatric psychiatry, and quantitative and qualitative health services research. The training goals are to gain skills in intervention design and implementation science, qualitative data analysis, and longitudinal data analysis. These goals will be met with a mixture of courses, readings, cyber and in-person seminars, frequent discussions with mentors, and conferences. Weekly in-person meetings will be held with the co-primary mentors, Kenneth Boockvar, MD, MS, and Joan Penrod, MA, MSW, PhD, and monthly phone calls will be held with the secondary mentors, Christopher Johnson, PhD, and Holly Prigerson, PhD.