Defining Optimal Care for Urinary Stone Disease in the Veterans Health Administration
Alan C Pao
Palo Alto, CA
October 2020 -
Background: Urinary stone disease (USD) imposes a major economic and health burden on the United States and the Veterans Health Administration (VHA). The current barriers to delivering optimal health care to patients with USD is the dearth of evidence-based process measures and treatments and the complexity of secondary prevention measures for USD. Significance/Impact: Current guidelines for best practice management of USD are largely based on clinical principles or expert opinion. The VHA/DoD has not developed clinical practice guidelines for USD because there remains a critical need to determine what are the most effective prevention and treatment strategies to reduce USD risk. The relative lack of evidence-based guidelines may lead to suboptimal care and drive unwanted practice pattern variability of quality of care for USD. The proposed research will address the following VHA/ORD priorities: Primary care practice and management of complex chronic diseases (such as recurrent USD) and quality measurement of USD prevention. Innovation: As a first step to address uncertainty in the best practice management of USD, we aim to test whether multidisciplinary specialty care structure is associated with guideline- concordant care and improved outcomes for USD. The findings from proposed research may inform efforts to include more specialty care options in the management of patients with USD, such as implementation of e-consult or telehealth modalities as a way to expand access of Veterans to quality care for USD. Specific Aims: The main objectives are the following: 1) Identify unwanted variation in USD care in the VHA; and 2) Test whether multidisciplinary specialty care structure is associated with guideline-concordant care and improved outcomes for Veterans with USD. We hypothesize that multidisciplinary specialty care is associated with guideline-concordant care and improved outcomes for Veterans with USD. We propose the following specific aims: 1) Evaluate facility- level variation of guideline-concordant care for patients with USD in the VHA; 2) Determine whether multidisciplinary care is associated with guideline-concordant USD care; and 3) Test whether multidisciplinary care is associated with improved USD outcomes. Methodology: Aim 1 will calculate a composite guideline-concordance score for each patient with USD and summarize variation in guideline-concordant care for USD by VHA facility. Aim 2 will use mixed effects multivariable models to determine relationships among outpatient care with primary care, specialty care, and guideline-concordant care. Aim 3 will develop a mixed effects time-to-event model, incorporating provider care structure and composite guideline- concordant score, to test whether multidisciplinary care is associated with improved outcomes. Next Steps/Implementation: The VHA is ideally positioned to support comparative effectiveness studies to determine which USD treatment paradigms are most effective at reducing USD recurrence. Findings from the proposed will define more clearly best practice management of USD, reduce unwanted variation in USD care, and inform future quality improvement efforts in both the VA and civilian health care systems.