Each year, VA provides care to more than 46,000 Veterans residing in 132 VA nursing homes, known as Community Living Centers (CLCs). The CLC is a key setting for the delivery of end-of-life (EOL) care, and encouraging appropriate palliative care, avoiding burdensome interventions, and supporting treatment decisions that maximize quality of life are major priorities for this population. An aspect of palliative care that has tremendous potential to positively impact VA CLC residents with limited life expectancy and/or advanced dementia (LLE/AD) is the de-intensification of chronic disease medications that have reduced potential benefits and increased risks and burdens in the context of LLE/AD. In the years leading up to the development of AD and other life-limiting conditions, most CLC residents have accumulated multiple chronic conditions requiring medication therapy (e.g., coronary artery disease, hypertension, diabetes). However, practice guidelines developed for general populations calling for intense treatment of these conditions may no longer be appropriate for residents with LLE/AD, given their reduced potential to live long enough to experience benefits and higher propensity for adverse drug reactions. Several groups have issued recommendations for intense chronic disease treatments to avoid in patients with LLE/AD, but their adoption in CLC practice is unknown. These LLE/AD-specific recommendations are also largely based on expert consensus about hypothesized risks and benefits, rather than direct evidence about actual risks and benefits from rigorously designed studies with LLE/AD patients.
Specific aims are to: (1) describe patterns of receipt of intense vs. de-intensified treatment for lipid, blood pressure (BP), and glycemic control in Veterans with LLE/AD after CLC admission; (2) examine effects of intense treatment for lipid, BP, and glycemic control after CLC admission on all-cause negative events and disease-specific hospitalizations and emergency visits in Veterans with LLE/AD; and (3) identify key barriers and facilitators to implementing LLE/AD-specific recommendations and design an intervention toolkit to serve as the basis for quality improvement (QI) efforts.
This is a mixed-methods study with two phases. For quantitative aims 1-2, we will: link Minimum Dataset (MDS) assessments, medication records, VA utilization/clinical data, and Medicare claims to examine variation across CLCs in intense vs. de-intensified treatment; identify patient, caregiver, provider, and facility factors contributing to this variation; and determine effects on all-cause and disease-specific negative events. Our analytic approach uses propensity score methods with inverse probability of treatment weights to minimize selection bias and confounding. Using results from Aim 1 to purposively sample from CLCs with lower proportions of intensely treated residents ("early adopters" of LLE/AD recommendations) and higher proportions of intensely treated residents ("late adopters"), qualitative Aim 3 will involve semi-structured interviews with providers and family caregivers of recently deceased CLC residents. With input from VA clinical and operational partners, we will use these data to map key barriers and facilitators to implementing LLE/AD-specific recommendations and develop an intervention toolkit that will serve as a basis for future QI efforts.
Not yet available.
The long-term goal of this research is to improve quality of care provided to VA CLC residents with LLE/AD, through the safe and effective use of medication that is aligned with their goals of care. This study addresses the HSR&D Priority Area on Long-Term Care and Caregiving and Strategies 1-3 of the VA Blueprint for Excellence. It will have significant impact by providing VA with critical information and tools needed to optimize QI efforts to facilitate implementation of LLE/AD-specific treatment recommendations and support improved shared decision-making about medications in CLC residents near end-of-life.
- Miller SC, Intrator O, Scott W, Shreve ST, Phibbs CS, Kinosian B, Allman RM, Edes TE. Increasing Veterans' Hospice Use: The Veterans Health Administration's Focus On Improving End-Of-Life Care. Health affairs (Project Hope). 2017 Jul 1; 36(7):1274-1282.
Aging, Older Veterans' Health and Care
TRL - Applied/Translational
Best Practices, Cardiovascular Disease, Decision-Making, Dementia, Diabetes, End-of-Life, Medication Management, Outcomes - Patient, Practice Patterns/Trends