Improving Implementation of Outpatient Goals of Care Conversations for Veteranswith Serious Illness

背景：退伍军人管理局实施了生命维持治疗决策倡议(LSTDI)，以引出、记录、 尊重患有严重疾病的退伍军人的价值观、目标和偏好。美国国家科学院 医学建议，患者和家属更喜欢护理对话的目标( LSTDI)发生在他们在门诊环境中病情不是很严重时。然而，在退伍军人管理局全国范围内，大多数目标 的护理对话发生在濒临死亡的住院患者环境中；只有39%的患者发生在门诊环境中。 意义/影响：本研究将确定改善门诊患者LSTDI实施的策略 布景。这对退伍军人来说意义重大，因为它确保了他们能够表达自己的目标和对生活的偏好 持续的治疗并让他们受到尊重。涉及退伍军人事务部秘书的两个优先事项：(1)目标是 提供关于维持生命治疗的“明确信息以作出明智的决定”，以及(2) 退伍军人将获得“关怀和支持…”在整个过程中强调他们的幸福和独立 人生旅途。“这项提案旨在通过以下方式解决研发目标，即增加退伍军人管理局研究的实际影响 了解如何改进国家退伍军人政策的执行。与高铁和研发的优先顺序保持一致 建议书中所描述的。 创新：该方案采用了创新的研究设计，即序贯多分配随机试验 (智能)。面向患者和面向提供商的实施战略的结合，被认为是重要的 在我们的初步研究中，也是具有创新性的。最后，我们采用基于人口的方法来理解 患有严重非癌症疾病的重病退伍军人护理对话目标的实施 包括心力衰竭和慢性肺、肾和肾脏疾病。 明确的目标。目的1.在三个退伍军人健康系统中使用临床医生级别的SMART来确定有效性 临床医生和患者实施策略，以改善记录在案的护理目标的发生 与患有严重疾病的退伍军人的对话。目标2a。确定实施顺序 导致护理对话目标的总体最大增长的战略。目标2b (探索性)。确定修改实施顺序效果的患者和临床医生特征 记录护理对话目标的策略。目标3.了解临床医生和患者 使用混合方法评估实施策略的成败，包括临床医生、领导者、 病人和照顾者。 研究方法：研究地点包括退伍军人事务部、东科罗拉多州、大洛杉矶和帕洛阿尔托医疗保健 系统。我们将以退伍军人中护理对话的低目标率的临床医生为目标 疾病在住院或死亡风险的前10%。我们将首先测试资源密集度较低的产品 战略，并随后随机选择具有持续较低对话率的PACT团队 增加当前战略的强度或花更多的时间在当前战略上。数据将从以下地点收集 退伍军人事务部数据仓库(目标1和2)以及患者、护理者和临床医生的访谈或调查 (目标2和3)。数据将使用定性和定量的方法进行分析。 下一步/实施：将与我们的运营合作伙伴合作传播研究结果 (国家卫生保健、初级保健、姑息治疗伦理中心)我们的合作伙伴可以实施政策 根据研究结果，增加LSTDI的早期门诊实施。

Background: VA implemented the Life Sustaining Treatment Decisions Initiative (LSTDI) to elicit, document, and honor the values, goals, and preferences of Veterans with serious illness. The National Academy of Medicine recommends, and patients and families prefer goals of care conversations (the foundation of the LSTDI) occur when they are not acutely ill in the outpatient setting. However, across VA nationally, most goals of care conversations occur in the inpatient setting close to death; only 39% occur in the outpatient setting. Significance/Impact: This study will identify strategies to improve LSTDI implementation in the outpatient setting. This is significant to Veterans because it ensures they can express their goals and preferences for life sustaining treatments and have them honored. Two VA Secretary priorities are addressed: (1) the goal to provide “clear information to make informed decisions” about life-sustaining treatments, and (2) the goal for Veterans to receive “care and support… that emphasizes their well-being and independence throughout their life journey.” This proposal addresses the R&D goal to increase real-world impact of VA research by understanding how to improve implementation of a national VA policy. Alignment with HSR&D priorities is described in the proposal. Innovation: The proposal uses an innovative study design, a sequential multiple assignment randomized trial (SMART). The combination of patient-facing and provider-facing implementation strategies, deemed important in our preliminary studies, is also innovative. Finally, we take a population-based approach to understand the implementation of goals of care conversations in seriously ill Veterans with serious non-cancer illnesses including heart failure and chronic pulmonary, renal, and kidney diseases. Specific Aims. Aim 1. Use a clinician-level SMART in three VA health systems to determine the effectiveness of clinician and patient implementation strategies to improve the occurrence of documented goals of care conversations in Veterans with serious medical illness. Aim 2a. Identify the sequence of implementation strategies that leads to the overall greatest increase in documentation of goals of care conversations. Aim 2b (exploratory). Identify patient and clinician characteristics that modify the effect of sequences of implementation strategies on documentation of goals of care conversations. Aim 3. Understand clinician and patient implementation strategy success or failure using a mixed method evaluation involving clinicians, leaders, patients, and caregivers. Methodology: Study sites include the VA Eastern Colorado, Greater Los Angeles, and Palo Alto Health Care Systems. We will target clinicians with low rates of goals of care conversations among Veterans with medical illness in the top 10th percentile of risk of hospitalization or death. We will first test less resource intensive strategies, and subsequently randomize PACT teams with continued low rates of conversations to either an increased intensity of the current strategy or more time with the current strategy. Data will be collected from the VA Corporate Data Warehouse (Aims 1 and 2) and patient, caregiver, and clinician interviews or surveys (Aims 2 and 3). Data will be analyzed using qualitative and quantitative methods. Next Steps/Implementation: Study findings will be disseminated in collaboration with our operations partners (National Center for Ethics in Health Care, Primary Care, Palliative Care). Our partners can implement policies based on study findings to increase early, outpatient implementation of the LSTDI.