Document text
Principal Investigator: David B. Bekelman
Organization: VA EASTERN COLORADO HEALTH CARE SYSTEM
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: VA implemented the Life Sustaining Treatment Decisions Initiative (LSTDI) to elicit, document,
and honor the values, goals, and preferences of Veterans with serious illness. The National Academy of
Medicine recommends, and patients and families prefer goals of care conversations (the foundation of the
LSTDI) occur when they are not acutely ill in the outpatient setting. However, across VA nationally, most goals
of care conversations occur in the inpatient setting close to death; only 39% occur in the outpatient setting.
Significance/Impact: This study will identify strategies to improve LSTDI implementation in the outpatient
setting. This is significant to Veterans because it ensures they can express their goals and preferences for life
sustaining treatments and have them honored. Two VA Secretary priorities are addressed: (1) the goal to
provide “clear information to make informed decisions” about life-sustaining treatments, and (2) the goal for
Veterans to receive “care and support… that emphasizes their well-being and independence throughout their
life journey.” This proposal addresses the R&D goal to increase real-world impact of VA research by
understanding how to improve implementation of a national VA policy. Alignment with HSR&D priorities is
described in the proposal.
Innovation: The proposal uses an innovative study design, a sequential multiple assignment randomized trial
(SMART). The combination of patient-facing and provider-facing implementation strategies, deemed important
in our preliminary studies, is also innovative. Finally, we take a population-based approach to understand the
implementation of goals of care conversations in seriously ill Veterans with serious non-cancer illnesses
including heart failure and chronic pulmonary, renal, and kidney diseases.
Specific Aims. Aim 1. Use a clinician-level SMART in three VA health systems to determine the effectiveness
of clinician and patient implementation strategies to improve the occurrence of documented goals of care
conversations in Veterans with serious medical illness. Aim 2a. Identify the sequence of implementation
strategies that leads to the overall greatest increase in documentation of goals of care conversations. Aim 2b
(exploratory). Identify patient and clinician characteristics that modify the effect of sequences of implementation
strategies on documentation of goals of care conversations. Aim 3. Understand clinician and patient
implementation strategy success or failure using a mixed method evaluation involving clinicians, leaders,
patients, and caregivers.
Methodology: Study sites include the VA Eastern Colorado, Greater Los Angeles, and Palo Alto Health Care
Systems. We will target clinicians with low rates of goals of care conversations among Veterans with medical
illness in the top 10th percentile of risk of hospitalization or death. We will first test less resource intensive
strategies, and subsequently randomize PACT teams with continued low rates of conversations to either an
increased intensity of the current strategy or more time with the current strategy. Data will be collected from
the VA Corporate Data Warehouse (Aims 1 and 2) and patient, caregiver, and clinician interviews or surveys
(Aims 2 and 3). Data will be analyzed using qualitative and quantitative methods.
Next Steps/Implementation: Study findings will be disseminated in collaboration with our operations partners
(National Center for Ethics in Health Care, Primary Care, Palliative Care). Our partners can implement policies
based on study findings to increase early, outpatient implementation of the LSTDI.
Terms: <Academy><Address><Amentia><Breathing><COPD><COVID associated morbidity><COVID induced morbidity><COVID morbidity><COVID related morbidity><COVID-19><COVID-19 associated death><COVID-19 associated fatality><COVID-19 associated morbidity><COVID-19 associated mortality><COVID-19 death><COVID-19 fatality><COVID-19 induced death><COVID-19 induced fatality><COVID-19 induced morbidity><COVID-19 induced mortality><COVID-19 morbidity><COVID-19 mortality><COVID-19 related death><COVID-19 related fatality><COVID-19 related morbidity><COVID-19 related mortality><COVID19 associated death><COVID19 associated fatality><COVID19 associated mortality><COVID19 death><COVID19 fatality><COVID19 induced death><COVID19 induced fatality><COVID19 induced mortality><COVID19 mortality><COVID19 related death><COVID19 related fatality><COVID19 related mortality><CV-19><Cancers><Cardiopulmonary Resuscitation><Care Givers><Caregivers><Caring><Cessation of life><Characteristics><Chronic Disease><Chronic Illness><Chronic Obstruction Pulmonary Disease><Chronic Obstructive Lung Disease><Chronic Obstructive Pulmonary Disease><Collaborations><Colorado><Coronavirus Infectious Disease 2019><Data><Death><Dementia><Development and Research><Documentation><Ensure><Ethics><Evaluation><Failure><Family><Fostering><Foundations><Goals><Health><Health Care Providers><Health Care Systems><Health Personnel><Health system><Healthcare><Healthcare Providers><Healthcare Systems><Healthcare worker><Heart failure><Hepatic Disorder><Hospital Admission><Hospitalization><Inpatients><Interview><Kidney Diseases><Learning><Life><Liver diseases><Los Angeles><Lung Diseases><Malignant Neoplasms><Malignant Tumor><Mechanical ventilation><Medical><Medical center><Medicine><Methodology><Methods><Needs Assessment><Nephropathy><Out-patients><Outpatients><Palliative Care><Palliative Therapy><Palliative Treatment><Participant><Patients><Personal Satisfaction><Persons><Policies><Primary Care><Provider><Pulmonary Diseases><Pulmonary Disorder><R & D><R&D><Randomized><Recommendation><Renal Disease><Research><Research Design><Research Resources><Resources><Respiratory Aspiration><Respiratory Inspiration><Resuscitation><Risk><SARS-CoV-2 associated death><SARS-CoV-2 associated fatality><SARS-CoV-2 associated mortality><SARS-CoV-2 death><SARS-CoV-2 fatality><SARS-CoV-2 induced death><SARS-CoV-2 induced fatality><SARS-CoV-2 induced mortality><SARS-CoV-2 mortality><SARS-CoV-2 related death><SARS-CoV-2 related fatality><SARS-CoV-2 related mortality><Sequential Multiple Assignment Randomized Trial><Site><Study Type><Survey Instrument><Surveys><Testing><Time><Training><Veterans><Visit><assess effectiveness><cardiac failure><cardiac resuscitation><chronic disorder><chronic obstructive pulmonary disorder><comfort care><coronavirus disease 2019><coronavirus disease 2019 associated death><coronavirus disease 2019 associated fatality><coronavirus disease 2019 associated morbidity><coronavirus disease 2019 associated mortality><coronavirus disease 2019 death><coronavirus disease 2019 fatality><coronavirus disease 2019 induced death><coronavirus disease 2019 induced fatality><coronavirus disease 2019 induced morbidity><coronavirus disease 2019 induced mortality><coronavirus disease 2019 morbidity><coronavirus disease 2019 mortality><coronavirus disease 2019 related death><coronavirus disease 2019 related fatality><coronavirus disease 2019 related morbidity><coronavirus disease 2019 related mortality><coronavirus disease associated morbidity><coronavirus disease induced morbidity><coronavirus disease morbidity><coronavirus disease related morbidity><coronavirus disease-19><coronavirus disease-19 mortality><coronavirus infectious disease-19><data warehouse><death due to COVID-19><death due to COVID19><death due to SARS-CoV-2><death due to coronavirus disease 2019><death due to severe acute respiratory syndrome coronavirus 2><death in COVID><death in COVID-19><death in SARS-CoV-2><death in coronavirus disease><death in coronavirus disease 2019><death in severe acute respiratory syndrome coronavirus 2><decision-making capacity><determine effectiveness><disease of the lung><disorder of the lung><effectiveness assessment><effectiveness evaluation><end of life care><ethical><evaluate effectiveness><evidence base><examine effectiveness><experience><falls><fatality due to COVID-19><fatality due to COVID19><fatality due to SARS-CoV-2><fatality due to coronavirus disease 2019><fatality due to severe acute respiratory syndrome coronavirus 2><health care><health care personnel><health care worker><health provider><health workforce><healthcare personnel><heart resuscitation><hepatic disease><hepatopathy><high risk><implementation strategy><improved><innovate><innovation><innovative><inspiration><interest><kidney disorder><liver disorder><lung disorder><malignancy><mechanical respiratory assist><mechanically ventilated><medical personnel><meeting><meetings><member><mortality due to COVID-19><mortality due to COVID19><mortality due to SARS-CoV-2><mortality due to coronavirus disease 2019><mortality due to severe acute respiratory syndrome coronavirus 2><neoplasm/cancer><nutrition><operation><operations><population based><preference><prognostic><randomisation><randomization><randomly assigned><renal disorder><research and development><severe acute respiratory syndrome coronavirus 2 associated death><severe acute respiratory syndrome coronavirus 2 associated fatality><severe acute respiratory syndrome coronavirus 2 associated mortality><severe acute respiratory syndrome coronavirus 2 death><severe acute respiratory syndrome coronavirus 2 fatality><severe acute respiratory syndrome coronavirus 2 induced death><severe acute respiratory syndrome coronavirus 2 induced fatality><severe acute respiratory syndrome coronavirus 2 induced mortality><severe acute respiratory syndrome coronavirus 2 mortality><severe acute respiratory syndrome coronavirus 2 related death><severe acute respiratory syndrome coronavirus 2 related fatality><severe acute respiratory syndrome coronavirus 2 related mortality><strategies for implementation><study design><success><telehealth><treatment provider><web site><website><well-being><wellbeing>