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IIR 17-277 – HSR Study

IIR 17-277
Improving Palliative Measurement Application with Computer-Assisted-Abstraction Study
Karl A Lorenz, MD MSHS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Anne Walling MD PhD
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: October 2018 - March 2025


Background: VA needs to incorporate the Veteran and family voice in measuring performance, and it may improve care to involve Veterans and families more deeply in improvement. This is especially true for palliative and end of life care, given the 30% of lifetime Medicare costs in the last year of life, and the divergent perspectives that Americans have expressed regarding end of life care. We have identified major gaps in VA performance, but work is needed to prioritize indicators from the Veteran and family perspective and to improve measure feasibility. The latter will foster better VA quality and experience of care and facilitate monitoring the potential impact of paid, non-VA care on seriously ill Veterans. Aims: The Improving Palliative Measurement Application with Computer-Assisted-Abstraction Study (ImPACS), will prioritize measures and operationalize a subset of higher, intermediate, and lower feasibility process and utilization measures for palliative and end of life cancer care. We aim to: Aim 1: Solicit priorities from two Delphi panels - one of Veterans and families and a second of experts regarding process and healthcare use quality measures for advanced cancer care, including which of the 42 Cancer Quality ASSIST measures to extract, and conduct interviews regarding how to integrate Veterans and families in VA measurement and improvement for palliative and end of life cancer care, and Aim 2: Extract high priority process and utilization measures using natural language processing of VA charts and administrative data and in a sample drawn from Stanford and Dana Farber’s Healthcare's Epic systems, focusing on the domains of pain and opioids, mental health, and goals of care communication, and Aim 3: Examine associations of the extracted measures with Veteran characteristics, focusing on disparities in the care of rural and nonwhite Veterans and palliative care use. Methods: For Aim 1, we will recruit two Delphi panels - one of Veterans, family members, and a second of expert stakeholders. Veteran-family members will have experience with cancer. Experts will have expertise in the methods and application of quality measures. Purposive sampling will focus on critical attributes (e.g., race) that may affect priorities. Panelists will rate and rank measures within tiers of high, intermediate, and low feasibility, informed by reviews of the evidence for intervention and impact of performance gaps on patients and caregivers. We will also interview Veterans, family members and VA leaders at high and low performing VA facilities based on the Bereaved Family Survey of end of life experience, to see how deeper Veterans-family involvement might strengthen quality and experience of end of life care. For Aim 2, we will operationalize a subset of prioritized process measures from Aim 1 including Cancer Quality ASSIST measures using natural language processing of text notes and machine learning. In Aim 3, we will characterize variation in measures with Veteran characteristics focusing on known disparities among rural and nonwhite Veterans and palliative care services use. Impact: We will produce Veteran and family-informed priorities for a balanced measure set for palliative and end of life cancer care. We will inform how Veterans and families might be more deeply engaged in fostering improved quality and experience and fostering a learning healthcare system. Finally, we will extract prioritized measures using state of the art methods to improve their feasibility, characterize variation at the Veteran level focused on known disparities and palliative care potential to mitigate them.

External Links for this Project

NIH Reporter

Grant Number: I01HX002513-01A1

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Journal Articles

  1. O'Hanlon CE, Giannitrapani KF, Lindvall C, Gamboa RC, Canning M, Asch SM, Garrido MM, ImPACS Patient and Caregiver Panel, Walling AM, Lorenz KA. Correction to: Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures. Journal of general internal medicine. 2021 Nov 3. [view]
  2. O'Hanlon CE, Lindvall C, Giannitrapani KF, Garrido M, Ritchie C, Asch S, Gamboa RC, Canning M, Lorenz KA, Walling AM, ImPACS Expert Panel. Expert Stakeholder Prioritization of Process Quality Measures to Achieve Patient- and Family-Centered Palliative and End-of-Life Cancer Care. Journal of palliative medicine. 2021 Sep 1; 24(9):1321-1333. [view]
  3. Bradshaw C, Thomas IC, Montez-Rath ME, Lorenz KA, Asch SM, Leppert JT, Wang V, O'Hare AM, Kurella Tamura M. Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure. JAMA Network Open. 2021 Jan 4; 4(1):e2034084. [view]
  4. Coulourides Kogan A, Li O, Fields T, Mosqueda L, Lorenz K. Frontline provider perceptions of implementing home-based palliative care covered by an insurer. Health services research. 2022 Aug 1; 57(4):872-880. [view]
  5. Giannitrapani KF, Fereydooni S, Silveira MJ, Azarfar A, Glassman PA, Midboe A, Zenoni M, Becker WC, Lorenz KA. How Patients and Providers Weigh the Risks and Benefits of Long-Term Opioid Therapy for Cancer Pain. JCO oncology practice. 2021 Jul 1; 17(7):e1038-e1047. [view]
  6. D'Ambruoso SF, Glaspy JA, Hurvitz SA, Wenger NS, Pietras C, Ahmed K, Drakaki A, Goldman JW, Anand S, Simon W, Kung J, Coscarelli A, Rosen LS, Peddi PF, Wong DJL, Santos K, Phung P, Karlin D, Walling AM. Impact of a Palliative Care Nurse Practitioner in an Oncology Clinic: A Quality Improvement Effort. JCO oncology practice. 2022 Apr 1; 18(4):e484-e494. [view]
  7. Brown-Johnson C, Haverfield MC, Giannitrapani KF, Lo N, Lowery JS, Foglia MB, Walling AM, Bekelman DB, Shreve ST, Lehmann LS, Lorenz KA. Implementing Goals-of-Care Conversations: Lessons From High- and Low-Performing Sites From a VA National Initiative. Journal of pain and symptom management. 2021 Feb 1; 61(2):262-269. [view]
  8. O'Hanlon CE, Giannitrapani KF, Gamboa RC, Walling AM, Lindvall C, Garrido M, Asch SM, Lorenz KA. Integrating Patient and Expert Perspectives to Conceptualize High-Quality Palliative Cancer Care for Symptoms in the US Veterans Health Administration: A Qualitative Study. Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2023 Jan 1; 60:469580231160374. [view]
  9. O'Hanlon CE, Lindvall C, Lorenz KA, Giannitrapani KF, Garrido M, Asch SM, Wenger N, Malin J, Dy SM, Canning M, Gamboa RC, Walling AM. Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer. JCO oncology practice. 2021 Feb 1; 17(2):e140-e148. [view]
  10. Giannitrapani KF, Brown-Johnson C, McCaa M, Mckelvey J, Glassman P, Holliday J, Sandbrink F, Lorenz KA. Opportunities for improving opioid disposal practices in the Veterans Health Administration. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2021 Jun 23; 78(13):1216-1222. [view]
  11. O'Hanlon CE, Giannitrapani KF, Lindvall C, Gamboa RC, Canning M, Asch SM, Garrido MM, ImPACS Patient and Caregiver Panel, Walling AM, Lorenz KA. Patient and Caregiver Prioritization of Palliative and End-of-Life Cancer Care Quality Measures. Journal of general internal medicine. 2022 May 1; 37(6):1429-1435. [view]
  12. Singh N, Giannitrapani KF, Gamboa RC, O'Hanlon CE, Fereydooni S, Holdsworth LM, Lindvall C, Walling AM, Lorenz KA. What Patients Facing Cancer and Caregivers Want From Communication in Times of Crisis: A Qualitative Study in the Early Months of the COVID-19 Pandemic. The American journal of hospice & palliative care. 2023 Jun 30; 10499091231187351. [view]
Journal Other

  1. O'Hanlon CE, Walling AM, Lindvall C. Shortlist of Quality Indicators for End-of-Life Cancer Care. JAMA oncology. 2020 Jul 1; 6(7):1118-1119. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems, Other Conditions
DRE: Treatment - Observational, TRL - Development
Keywords: Care Coordination, End-of-Life, Family, Frailty, Social Support
MeSH Terms: None at this time.

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