Value of End-of-Life Cancer Care

临终癌症护理的价值

• 批准号: 9889081
• 负责人: Risha Gidwani Marszowski
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-03-01 至 2019-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9889081
• 关键词: Achievement; Admission activity; Advanced Malignant Neoplasm; Age; Agreement; American Society of Clinical Oncology; Cancer Patient; Caring; Characteristics; Communities; Community Services; Consensus; Cost Effectiveness Analysis; Data; Development; Emergency department visit; Enteral Feeding; Failure; Family; Frequencies; Goals; Grant; Health Benefit; Health Expenditures; Healthcare; Healthcare Systems; Homelessness; Hospitals; Institute of Medicine (U.S.); Intensive Care; Intensive Care Units; Length of Stay; Life; Literature; Malignant Neoplasms; Marital Status; Measures; Mechanical ventilation; Medical; Medicare; Methods; Oncology; Outcome; Pain management; Palliative Care; Patient-Centered Care; Patient-Focused Outcomes; Patients; Perception; Persons; Policy Maker; Process; Quality of Care; Quality of life; Race; Resources; Resuscitation; Rural; Services; Supportive care; Surveys; System; Unmarried; Veterans; base; cancer care; care costs; care outcomes; chemotherapy; cost; disparity reduction; end of life; end of life care; experience; health care disparity; hospice environment; improved; instrument; overtreatment; pain outcome; pain score; patient oriented; preference; rurality; sex; sociodemographic group; sociodemographic variables; sociodemographics; symptom management; wasting

 DESCRIPTION (provided by applicant): Project Impact: This project evaluates the value of specific types of medical care provided in the last four weeks of life to Veterans dying of cancer, using a patient-centered perspective. The VA's top goals, as stated in the Blueprint for Excellence, are to deliver personalized, proactive, and patient-driven healthcare and to deliver high-value care. However, it is not currently clear at the end of life, what particular types of services are undesirable and low-value from a patient/family perspective, and importantly, whether desires for end-of-life care differ across socio-demographic groups (e.g., based on rural status, homelessness, marital status). In the last four weeks of life, it is important that patients receive high-quality, preference-concordant care that prioritizes symptom management and quality-of-life enhancing treatments over intensive medical services. This project will provide actionable information to VA managers to improve the end-of-life care experience for the more than 21,000 Veterans who die each year with advanced cancer, while also improving the value of care. For example, our results may indicate chemotherapy in the last 14 days of life is high cost, has a small positive impact on patient-centered outcomes, and occurs at low frequency. They may also indicate, for example, that ICU stay in the last month of life is high cost, has a large negative effect on patient-centerd outcomes, and occurs with high frequency. These results would indicate that to improve the value and the patient experience of end-of-life care, VA should prioritize reducing unnecessary ICU admissions over reducing unnecessary chemotherapy. Background: The American Society of Clinical Oncology (ASCO) and the National Quality Forum (NQF) have categorized certain services as unduly intensive at the end of life. These are: chemotherapy in the last 14 days of life; intensive care unit (ICU) admission in the last 30 days of life; more than 1 Emergency Department (ED) visit in the last 30 days of life; not admitted to hospice; and admitted to hospice for less than 3 days. There is strong agreement in the oncology and quality-of-care communities these services are inappropriate and avoidable, and represent a failure to provide appropriate palliative and supportive care to patients. Objective: While the medical community has come to strong consensus as to what constitutes unduly intensive care at the end-of-life, we evaluate whether patients and families have the same perceptions of these services. Specifically, we evaluate the value of these intensive end-of-life services, using a patient-centered perspective. We also evaluate any disparities that may exist in the receipt of these services by Veteran priority status, race, sex, age, marital status, homelessness, or rural status. Methods: In healthcare, value indicates an achievement of outcomes proportional to the resources spent to achieve them. We therefore examine the value of specific end-of-life services through analyses of administrative data regarding processes of and cost of care at the end of life combined with patient-centered outcomes obtained from the Bereaved Family Survey. Our study will produce a value quadrant, similar to that seen in cost-effectiveness analyses. This value quadrant will indicate which intensive services have: a) a large impact on costs and a large impact on outcomes; b) a large impact on costs and a small impact on outcomes; c) a small impact on costs and a small impact on outcomes; and d) a small impact on costs and a large impact on outcomes. Our results will also indicate the frequency with which each intensive service occurs in VA. This information regarding the value of end-of-life care represents an entirely new contribution to the literature.

 描述（由申请人提供）： 项目影响：该项目采用以患者为中心的视角，评估在生命最后四个星期为死于癌症的退伍军人提供的特定类型的医疗护理的价值，如卓越蓝图所述，VA 的首要目标是：提供个性化、主动且以患者为导向的医疗保健并提供高价值的护理但是，目前尚不清楚。 临终时，从患者/家庭的角度来看，哪些特定类型的服务是不受欢迎的和低价值的，重要的是，不同社会人口群体对临终关怀的渴望是否不同（例如，基于农村地位、无家可归）在生命的最后四个星期，患者接受高质量、符合偏好的护理非常重要，该护理优先考虑症状管理和提高生活质量的治疗，而不是强化医疗服务。该项目将为 VA 管理人员提供可操作的信息，以改善其质量。每年超过 21,000 名死于晚期癌症的退伍军人的临终护理体验，同时也提高了护理价值。例如，我们的结果可能表明生命最后 14 天的化疗成本很高。例如，它们还可能表明，在生命最后一个月入住 ICU 的成本很高，对以患者为中心的结果有很大的负面影响，并且发生频率较低。具有高频率。这表明，为了提高临终关怀的价值和患者体验，VA 应优先考虑减少不必要的 ICU 入院而不是减少不必要的化疗。 背景：美国临床肿瘤学会 (ASCO) 和国家质量论坛 (NQF)。在生命结束时将某些服务归类为过度密集，包括： 生命最后 14 天内接受化疗； 生命最后 30 天内入住重症监护病房 (ICU) 次数超过 1 次；最后一个生命已满 30 天；未入住临终关怀中心；且入住临终关怀中心的时间少于 3 天。目的：虽然医学界对于临终时过度重症监护的构成已达成强烈共识，但我们评估患者和家属对这些服务是否有相同的看法。这些的价值我们还采用以患者为中心的视角，评估退伍军人优先地位、种族、性别、年龄、婚姻状况、无家可归或农村状况在接受这些服务方面可能存在的任何差异。 方法：在医疗保健领域，价值表示所取得的成果与实现这些成果所花费的资源成正比，因此我们通过分析有关临终护理流程和成本的管理数据来研究特定临终服务的价值。结合从丧亲家庭调查中获得的以患者为中心的结果，我们的研究将产生一个价值象限，类似于成本效益分析中的结果。该价值象限将表明哪些强化服务具有：a）对成本和a）的巨大影响。对结果影响大；对成本影响小，对结果影响小；c) 对成本影响小，对结果影响小；以及 d) 对成本影响小，对结果影响大。这一关于临终关怀价值的信息代表了对文献的全新贡献。