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Health Services Research & Development

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IIR 19-106 – HSR&D Study

 
IIR 19-106
Outpatient Palliative Care and Prescribing Safety and Quality at End-of-Life
Joshua M. Thorpe PhD MPH
Pittsburgh, PA
Funding Period: August 2020 - January 2024

Abstract

Background: The long-term goal of this research is to support the ability of Veterans with life-limiting conditions (LLCs) to remain living their communities by ensuring access to the highest possible quality of care; including long-term care support services like palliative care. Given their complex healthcare needs, Veterans with LLCs often manage many different medications, each carrying their own risk/benefit profile. Unfortunately, complex medication regimens are a significant risk factor for receiving potentially unsafe medications or being over- treated for chronic conditions such as high cholesterol and diabetes. Significance/Impact: A key component of palliative care that can assist Veterans is ensuring that medication therapy is aligned with patients’ and families’ goals of care. Palliative care, therefore, provides a critical opportunity to deprescribe or de-intensity potentially harmful or unnecessary medications. Outpatient palliative care (OPC) is a growing community-based medical service known to improve access to palliative care for patients living in the community. OPC is also underutilized, and little is known about potential barriers to receiving OPC services. Innovation: Our study is highly innovative 4 key ways: (1) outpatient palliative care is a relatively new, community-based, long-term care service offered to Veterans, and OPC is still underutilized across the VA; (2) It is the first study to evaluate the comparative effectiveness of OPC versus usual care in the VA; (3) Veterans with LLCs prefer to remain in non-institutional settings. However, community-based care is not covered by the regulations that monitor the quality of care in their nursing home counterparts. This research is therefore essential for developing community-based performance metrics to monitor the quality of care in community-dwelling Veterans with LLCs; and (4) VA policy directives state that VA palliative care teams are necessarily multidisciplinary. This mixed-methods study is novel in its use of semi-structured interviews that will include different provider-types comprising a palliative care team. Specific Aims: The specific aims are to: (1) determine the extent to which variation in OPC use exists across VA facilities, and identify patient- and facility-level factors that contribute to this variation; (2) evaluating the comparative effectiveness of OPC (versus traditional outpatient care use) on deprescribing of potentially unsafe medications (PUMs), and deintensification of unnecessary chronic disease medications in Veterans with LLC; and (3) explore VA palliative care provider perspectives about barriers and facilitators to using OPC and to effectively addressing the deprescribing unsafe or unnecessary medications in Veterans with LLCs. Methodology: The quantitative phase of this mixed-method study will involve analyses of VA and Medicare data in over 2,000,000 Veterans with LLC. Pooling data from 2010-2017, we will link inpatient, outpatient, nursing home, vital status, and medication data from VA and Medicare to develop a national cohort of Veterans with LLCs. Our analytic approach involves propensity score weighting and instrumental variables to address potential selection bias associated with OPC use. The qualitative phase will involve semi-structured interviews of VA outpatient palliative care providers to assist in interpreting quantitative results and gain additional insights about barriers to OPC use and challenges with managing medications. Next Steps/Implementation: Together, these aims will assist both VA and non-VA healthcare systems in making evidence-based decisions about improvements and expansions to OPC services, and to better design policies and interventions to ensure safe and effective medication use at end-of-life.

External Links for this Project

NIH Reporter

Grant Number: I01HX003059-01
Link: https://reporter.nih.gov/project-details/9835692



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PUBLICATIONS:


Journal Articles

  1. Alexopoulos AS, Kahkoska AR, Pate V, Bradley MC, Niznik J, Thorpe C, Stürmer T, Buse J. Deintensification of Treatment With Sulfonylurea and Insulin After Severe Hypoglycemia Among Older Adults With Diabetes. JAMA Network Open. 2021 Nov 1; 4(11):e2132215. [view]
  2. Smith VA, Van Houtven CH, Lindquist JH, Hastings SN. Evaluation of a geriatrics primary care model using prospective matching to guide enrollment. BMC medical research methodology. 2021 Aug 16; 21(1):167. [view]
  3. Jacobs JC, Maciejeweski ML, Wagner TH, Van Houtven CH, Lo J, Greene L, Zulman DM. Improving Prediction of Long-Term Care Utilization Through Patient-Reported Measures: Cross-Sectional Analysis of High-Need U.S. Veterans Affairs Patients. Medical care research and review : MCRR. 2021 Dec 14; 10775587211062403. [view]
  4. Boucher NA, Zullig LL, Shepherd-Banigan M, Decosimo KP, Dadolf J, Choate A, Mahanna EP, Sperber NR, Wang V, Allen KA, Hastings SN, Van Houtven CH. Replicating an effective VA program to train and support family caregivers: a hybrid type III effectiveness-implementation design. BMC health services research. 2021 May 6; 21(1):430. [view]
  5. Allen KD, Woolson S, Hoenig HM, Bongiorni D, Byrd J, Caves K, Hall KS, Heiderscheit B, Hodges NJ, Huffman KM, Morey MC, Ramasunder S, Severson H, Van Houtven C, Abbate LM, Coffman CJ. Stepped Exercise Program for Patients With Knee Osteoarthritis : A Randomized Controlled Trial. Annals of internal medicine. 2021 Mar 1; 174(3):298-307. [view]
  6. Hughes JM, Bartle JT, Choate AL, Mahanna EP, Meyer CL, Tucker MC, Wang V, Allen KD, Van Houtven CH, Hastings SN. Walking All over COVID-19: The Rapid Development of , an Innovative Approach to Enhance a Hospital-Based Walking Program during the Pandemic. Geriatrics (Basel, Switzerland). 2021 Nov 10; 6(4). [view]


DRA: Aging, Older Veterans' Health and Care, Health Systems, Acute and Combat-Related Injury, Cardiovascular Disease
DRE: Treatment - Observational, Treatment - Comparative Effectiveness, TRL - Applied/Translational
Keywords: End-of-Life, Home Care, Hospice, Pharmacology
MeSH Terms: None at this time.

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