A Layered Examination of the Patient Experience to Elucidate the Role of Palliative Care in Surgical Care for Seriously Ill Older Adults

对患者体验进行分层检查，以阐明姑息治疗在重病老年人手术治疗中的作用

• 批准号: 10831621
• 负责人: Zara R Cooper
• 金额: $ 13.87万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-08-01 至 2026-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10831621
• 关键词: Acute; Address; Administrator; Adult; Caregiver Burden; Caregivers; Caring; Certification; Clinical; Colectomy; Communities; Community Hospitals; Coronary Artery Bypass; Data; Data Sources; Documentation; Elderly; Emergency department visit; End stage renal failure; Goals; Guidelines; Health; Health and Retirement Study; Health system; Healthcare; Healthcare Systems; Hospitalization; Hospitals; Impaired cognition; Intervention; Interview; Life; Link; Lower Extremity; Malignant Neoplasms; Manuals; Massachusetts; Measures; Medicare claim; Mental Depression; Methodology; Methods; Natural Language Processing; Nurses; Operative Surgical Procedures; Outcome; Outcomes Research; Pain; Palliative Care; Patient-Focused Outcomes; Patients; Perioperative; Physicians; Population; Postoperative Period; Process; Proxy; Qualitative Methods; Quality of life; Research; Retrospective cohort; Risk; Role; Site; Social Workers; Specialist; Surgical Injuries; Surgical complication; Testing; Trauma; United States National Institutes of Health; Vascularization; Work; care delivery; caregiver strain; caregiving; clinical practice; cohort; contextual factors; daily functioning; electronic health data; end of life care; experience; functional decline; health care service utilization; health data; health goals; high risk; hip replacement arthroplasty; hospice environment; implementation barriers; improved; improved outcome; informal caregiving; information gathering; innovation; knee replacement arthroplasty; mortality; novel; nursing home length of stay; older patient; patient oriented; pragmatic implementation; psychologic; reduce symptoms; severe injury; social; surgery outcome

Project Summary . Over 1 million older (≥65 years) adults with serious illness have major surgery or severe trauma each year. After surgery or trauma, older seriously ill patients are at risk for increased healthcare use, functional and cognitive decline, and mortality. National quality guidelines highlight that palliative care focused on aligning treatments with health goals, improving quality of life, alleviating physical and psychological suffering, and addressing social needs, should be provided alongside surgical care at all stages of serious illness. Palliative care for hospitalized seriously ill patients is associated with reduced symptoms and less healthcare utilization after discharge. Although seriously ill surgical patients benefit from palliative care, they are less likely than other hospitalized patients to receive it; this is in part due to research gaps that have inhibited implementation of practical palliative care interventions for older seriously ill surgical patients. Gaps include a dearth of data on patient-oriented surgical outcomes such as pain, depression, and caregiving that can be targeted by palliative care, methodological barriers to measuring palliative care delivery in surgical practice, and little understanding of contextual factors that influence implementation of palliative care in surgery. The proposed study will address these gaps by providing an innovative and layered examination of the role of palliative care in surgery. The study has three specific aims. Aim 1 identifies a cohort of seriously ill older surgical patients (≥66y) using Health and Retirement Study data linked to Medicare claims, and determines the association between direct targets of palliative care (pain, depression, and caregiving needs) and less proximal benefits (reduced healthcare utilization) to demonstrate the important role of palliative care in surgery. Aim 2 identifies a retrospective cohort of older seriously ill surgical patients (≥66y) in a large regional health system and uses Natural Language Processing in electronic health data linked to Medicare Claims to identify palliative care processes (goals of care discussions, healthcare proxy documentation, pain and caregiver assessments) delivered during the surgical episode. The association between palliative care and healthcare utilization in the year after surgical discharge will be tested. Aim 3 uses qualitative interviews and direct observations to obtain an in-depth understanding of contextual factors influencing implementation of palliative care processes in the care of seriously ill older surgical patients (≥65 years). This proposal uses complementary data sources to assess patient-centered outcomes in older seriously ill surgical patients, uses novel methods to evaluate the impact of palliative care processes on outcomes, and deeply examines barriers to implementation of perioperative palliative care in clinical practice. These results will directly inform bedside clinical decisions and the implementation of targeted palliative care interventions to improve care for seriously ill older surgical patients.

项目摘要。 每年有超过100万年龄（≥65岁）患有严重疾病的成年人进行重大手术或严重的创伤。 手术或创伤后，年长的严重患者有可能增加医疗保健，功能性和 认知能力下降和死亡率。国家质量指南强调，姑息治疗的重点是对齐 具有健康目标，改善生活质量，减轻身体和心理苦难的治疗方法以及 在严重疾病的各个阶段，应与手术护理一起满足社会需求。姑息治疗 护理住院病患者患者的症状减少和医疗保健利用率降低有关 出院后。尽管病重的手术患者受益于姑息治疗，但他们的可能性少于 其他住院的患者接受它；这部分是由于抑制实施的研究空白 老年病重病患者的实用姑息治疗干预措施。差距包括数据死亡 以患者为导向的外科手术结果，例如疼痛，抑郁和护理，可以通过姑息治疗来定位 护理，测量手术实践中姑息治疗的方法论障碍，也很少理解 影响手术中姑息治疗实施的情境因素。拟议的研究将 通过对姑息治疗在手术中的作用进行创新和分层检查来解决这些差距。 该研究具有三个特定的目标。 AIM 1使用使用严重病重的外科手术患者（≥66岁）的队列 健康和退休研究数据与Medicare主张有关，并确定直接的关联 姑息治疗（疼痛，抑郁和照料需求）的目标和近端益处（减少 医疗保健利用）以证明姑息治疗在手术中的重要作用。 AIM 2标识 大型区域卫生系统中老年认真手术患者（≥66岁）的回顾性队列 与Medicare索赔有关的电子健康数据中的自然语言处理以识别姑息治疗 流程（护理讨论的目标，医疗保健替代文档，疼痛和照顾者评估） 在手术情节中交付。姑息治疗与医疗保健利用之间的关联 手术放电后的一年。 AIM 3使用定性访谈和直接观察来获得 对上下文因素的深入理解会影响姑息治疗过程的实施 照顾重病老年手术患者（≥65岁）。该建议使用完整的数据源 评估年龄较大的严重患者中以患者为中心的结局，使用新方法评估 姑息治疗过程对结果的影响，并深入研究实施的障碍 临床实践中的围手术期姑息治疗。这些结果将直接告知床边临床决策，并 实施有针对性的姑息治疗干预措施，以改善对年龄较老的手术的护理 患者。