Each year, VA cares for thousands of Veterans in 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. 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 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, and actual benefits and risks to patients associated with their implementation, is unknown.
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; 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.
We have obtained and linked data for quantitative aims 1-2. We have validated our approach for using the MDS to identify patients with LLE, and identified a sample of 58,908 CLC episodes in FY2009-2015 lasting at least 7 days for Veterans aged 65 years of age who have evidence of LLE/AD at admission. Preliminary analyses of the subsample with coronary artery disease, history of stroke/transient ischemic attack, and/or diabetes (n=44,041) reveal that 36% of these Veterans receive intense treatment for lipid control; i.e., they are treated with statins at CLC admission. Approximately 21% of patients initially treated with statins at admission subsequently discontinue statin use within 90 days.
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 improve quality and safety of prescribing and shared decision-making in CLC residents near end-of-life.
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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