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.

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DRA: Aging, Older Veterans' Health and Care, Health Systems Science, Acute and Combat-Related Injury, Cardiovascular Disease

DRE: TRL - Applied/Translational, Treatment - Observational, Treatment - Comparative Effectiveness

Keywords: End-of-Life, Home Care, Hospice, Pharmacology

MeSH Terms: None at this time.