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

背景：退伍军人转诊到专科护理的比率低是获得专科护理的重大障碍 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， 晚期慢性肾脏病(CKD)、失代偿期肝硬变)，有可能有资格救命 而且需要专门的护理，以实现最佳的疾病管理。尽管患病率很高，但 退伍军人中终末期肝肾疾病，不到三分之一的退伍军人患有晚期慢性肾脏病和 失代偿性肝硬变被推荐给专家和5%的人进行移植评估。一个全面的 评估影响专科护理转诊的患者、提供者和系统层面的因素 移植评估对于制定有针对性的战略和方法以优化转诊至关重要 合适性，因为在被专家看和提高存活率之间有明显的关联。 意义/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 对患有晚期慢性肝肾疾病的退伍军人的评估还不完全具有特征性。 这些知识对于设计有效的策略以提高推荐的适当性和优化 进入。因此，迫切需要改善我们对这些复杂关系的理解，这一需求尚未得到满足 以及它们影响转诊到专科护理和转诊进行移植评估的机制。 创新：大多数现有工作都集中在转诊到专科护理和治疗的下游步骤 移植评估，如完成移植评估、等待名单、移植收据和移植后评估 移植结果--因此，专科护理转诊和移植评估转诊的障碍依然存在 未得到充分研究。这项研究将全面审查和确定推动转诊的多层面因素 移植评估的专门护理和转诊，目标是产生最佳做法建议 优化转诊适当性和公平性。这方面的知识对于改进推荐至关重要。 进程/途径，加强老一辈的成果，并为政策变化提供信息，以提高机会的平等性。 目标：1)描述与专科转诊和移植转诊相关的多层次因素 对晚期慢性肝肾疾病患者的评估。2)检查患者和提供者 移植专科护理转诊和转诊的知识、态度和感知障碍/促进者 评估。3)制定最佳做法建议，以优化转介的适当性和公平使用 修改后的Delphi面板。 项目方法：AIM 1是一项使用多水平建模来确定关键因素的回溯性观察队列研究 与非转诊到专科护理和移植相关的患者、提供者和系统层面的因素 评估。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 移植评估也将进行评估。在目标2中，我们将进行半结构化的定性访谈 从6个退伍军人健康系统中抽取初级和专科护理提供者和患者，以探索差异 在转诊到专科护理和移植方面的知识、态度和感知的障碍/促进者 评估。在目标3中，我们将使用改进的Delphi方法召集退伍军人管理局业务负责人的两个小组 和其他专家制定最佳做法建议，以最大限度地提高转介的适当性和公正性。 实施/下一步：这项研究将提供有关影响关键因素的关键信息 对患有晚期慢性病的脆弱退伍军人进行移植评估的专科护理转诊和转诊 肝脏和肾脏疾病。赠款的产品将向VHA领导人提供重要信息，告诉他们如何 通过制定可操作的战略来解决以下关键障碍，提高转介的适当性和公平性 转诊到专科护理和移植评估。

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.