IIR 23-125
IMPROving care for VEterans with Persistent Critical Illness (IMPROVE PerCI)
Elizabeth Viglianti, Ann Arbor Ann Arbor, MI Funding Period: October 2024 - September 2028 Portfolio Assignment: Care of Complex Chronic Conditions |
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AbstractBackground. The persistently critically ill—patients who remain in the intensive care unit (ICU) for at least 11 days—comprise 5% of ICU patients but account for 21% of ICU bed-days in the Veterans Health Administration (VHA). Nearly half of patients with persistent critical illness (PerCI) die in the subsequent year, and survivors are often left with new cognitive and/or physical impairments. There is an urgent need to identify strategies to improve quality of life (QoL) outcomes and survivorship for Veterans with PerCI. Significance. IMPROVE PerCI directly aligns with the VHA's Whole Health Initiative and Strategic Priorities for Research by prioritizing what matters to Veterans and their caregivers. Veteran-centered QoL outcomes are of particular importance and relevance following a hospitalization with PerCI. We recognize that simply focusing on mortality fails to acknowledge the impact these prolonged hospitalizations can have on the Veterans QoL. Identifying how variation in organizational care practices can lead to improved QoL outcomes for Veterans is essential. Importantly, the VHA provides care across the continuum from inpatient hospitalizations to outpatient follow-up visits, offering opportunities to identify innovative strategies to delivering Veteran centered care which improves their QoL. Innovation and Impact. IMPROVE PerCI is innovative in four specific ways. First, this will be the first national study of Veterans with PerCI and their caregivers to evaluate their QoL outcomes. Second, we will evaluate organizational mechanisms that differ among high- and low- performing VHA hospitals. Third, we will evaluate organizational practices at high performing survivorship VHAs through an implementation framework to readily translate practices into actionable recommendations. Lastly, we will use an innovative causal modeling approach, coincidence analysis, to evaluate the causality of the multifaceted practices implemented within VHA hospitals. Specific Aims. (A1) Identify high- and low-performing VHA hospitals for survival among Veterans with PerCI and understand the extent to which organizational factors differ. (A2) Elicit Veteran- and caregiver-survivorship experiences and QoL outcomes. (A3) Identify and define `best practices' at high-performing QoL VHA hospitals through detailed contextual hospital assessments and an innovative causal modeling approach (coincidence analysis). Methodology. Using VHA data from 2013-2022, we will calculate risk- and reliability-adjusted hospital-level 90-day post-discharge survival after a PerCI hospitalization. Among the 10 highest-and 10-lowest- 90-day post-discharge survival hospitals, we will assess if the organizational factors that are hypothesized to contribute to improved survivorship (e.g., closed ICU units) differ. We will empanel the 10-highest and 10-lowest 90-day post-discharge survival VHA hospitals (N=20) which will be used for the prospective survey collection in Aim 2. Prospective telephone surveys (N=500) of Veteran survivors 90- day post-discharge with PerCI will be conducted, focusing on their QoL outcomes. A nested cohort of semi- structured interviews with Veterans and caregivers (N=30) will be conducted to explore survivorship. Using the QoL survey outcomes, we will stratify the 20 VHA hospitals into high- and low- QoL outcome performers. We will select 8 hospitals (4 high and 4 low) and conduct detailed virtual interviews with ICU clinicians and administrators. Using the Tailored Implementation in Chronic Disease framework, we will evaluate institutional resources, policies, quality efforts, and contextual ICU characteristics that help or hinder a hospital's efforts. Coincidence analysis will be used to evaluate the causality of the multifaceted practices implemented within the VHA hospitals. Using an expert panel, we will assess the validity, improvement opportunity, and feasibility of these best practices to improve survivorship and develop a toolkit. Next Steps/Implementation. Upon successful completion of this research, we will work with our operational partners—who we have included in the design stage of this IIR— to test the best practices toolkit and identify strategies to incorporate them into the new VHA Electronic Health Record system through future hybrid effectiveness-implementation trials.
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External Links for this ProjectNIH ReporterGrant Number: I01HX003851-01A1Link: https://reporter.nih.gov/project-details/10992466 Dimensions for VADimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project
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