Deciding about Dialysis: Improving Decision-Making Among Older Adults with ESRD

决定是否进行透析：改善患有 ESRD 的老年人的决策

• 批准号: 9265380
• 负责人: MELISSA WACHTERMAN
• 金额: $ 15.5万
• 依托单位: HARVARD MEDICAL SCHOOL
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-08-15 至 2020-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9265380
• 关键词: Academic Medical Centers; Address; Adult; Aging; Appointment; Biometry; Boston; Caregiver Burden; Chronic Disease; Clinical; Clinical Investigator; Cognitive; Communication; Communication Barriers; Communities; Complement; Complex; Dana-Farber Cancer Institute; Data; Decision Aid; Decision Making; Dementia; Development; Dialysis patients; Dialysis procedure; Disease; Elderly; End stage renal failure; Ensure; Epidemiology; Evaluation; Family; Family member; Funding; Goals; Health Policy; Health Services; Health and Retirement Study; Healthcare Systems; Hearing; Hospitals; Impairment; Individual; International; Interview; Joints; K-Series Research Career Programs; Kidney Failure; Knowledge; Learning; Life; Life Expectancy; Link; Longevity; Longitudinal Surveys; Medical; Medicare; Medicare claim; Medicine; Melissa; Mentored Patient-Oriented Research Career Development Award; Mentors; Mentorship; Modeling; Nephrology; Pain; Palliative Care; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Phase; Physicians; Process; Qualitative Research; Quality of Care; Quality of life; Randomized Controlled Trials; Regrets; Research; Research Methodology; Research Personnel; Resources; Science; Series; Surveys; Symptoms; Talents; Testing; Time; Training; Transition Career Development Award (K22); Woman; Work; aged; burden of illness; career; career development; cognitive function; demographics; design; end of life care; expectation; experience; functional status; health data; improved; longitudinal analysis; medical schools; mid-career faculty; mortality; older patient; outcome forecast; patient oriented; preference; prognostic; public health relevance; reduce symptoms; shared decision making; skills; success; treatment center

 DESCRIPTION (provided by applicant): Individuals 70 and older are the fastest growing group of patients with end-stage renal disease (ESRD). Research shows that decision-making regarding initiation of dialysis is impaired by poor communication and lack of understanding about the options for management of ESRD. Some small studies suggest that, among older adults, dialysis may be associated with longer life expectancy but possibly worse quality of life, compared to conservative management without dialysis. Yet little is known about what older adults can expect after initiating dialysis in terms of patient-centered outcomes such as functional status and cognitive function. Furthermore, even though the choice regarding dialysis initiation involves a series of difficult trade-offs between potential longevity gains with dialysi and potentially better quality of life with conservative management, there has been little research into patient, family, and clinician perspectives on this decision-making process, and very few resources exist to promote decision-making that reflects patients' values and informed treatment preferences. This proposal has the following three interrelated and complementary aims that address these challenges related to dialysis decision-making: 1) Define the trajectories of functional status and cognitive function for adults 70 and older with ESRD before and after initiation of dialysis, compared to the trajectories of adults not on dialysis. 2) Explor perspectives about the decision to initiate dialysis (versus maximum conservative management) among adults 70 and older, their families, and clinicians. 3) Develop and pilot test a decision aid for decisionally-capable older patients with impending ESRD and their families, designed to improve knowledge about dialysis and conservative management options and to improve clarity about one's values and treatment preferences. The first project is a quantitative analysis using nationally-representative longitudinal survey data from the Health and Retirement Study, linked with Medicare claims. The second project features qualitative semistructured interviews with patients, family members, and clinicians who are at different points in the decisionmaking process (before and after deciding about dialysis). The third project will use the knowledge gained from Aims 1 and 2 to inform the design of a decision aid specifically for decisionally-capable adults 70 and older who are expected to need dialysis within 12 months, which will be pilot-tested with patients. The results from Aim 3 will contribute preliminary data to an R01 proposal of a randomized-controlled trial of the decision aid. The overall objective of this K23 Career Development Award is to support the early career of Dr. Melissa Wachterman, a palliative care physician and health services researcher at Harvard Medical School. Dr. Wachterman is a promising junior investigator specializing in research related to geriatric palliative care. Her career goal is to become an independently-funded clinician-investigator conducting research that improves quality of care and patient-centered treatment decision-making for seriously-ill older adults and their families. This proposal builds o Dr. Wachterman's prior research on end-of-life care for older adults with chronic diseases such as dementia and her more recent work exploring older patients' perspectives on dialysis and communication barriers between nephrologists and patients when discussing prognosis. This K23 award will help Dr. Wachterman accomplish the following goals: 1) to obtain advanced training in biostatistics and epidemiology, including analytic skills using both longitudinal nationallyrepresentative survey data and administrative data; 2) to acquire advanced training in qualitative research methods; 3) to acquire an understanding of theoretical frameworks of shared decision-making and develop skills in decision aid development and evaluation; 4) to develop as an investigator to ensure a successful transition from this career development award to independent R01-level funding. To achieve these goals, Dr. Wachterman has chosen a mentoring team committed to her success as a clinician investigator that capitalizes on her joint appointments at three leading academic medical centers affiliated with Harvard Medical School: Brigham and Women's Hospital, VA Boston Healthcare System, and Dana Farber Cancer Institute. Her primary mentor is Dr. Nancy Keating, Associate Professor of Medicine and Health Policy at Harvard Medical School and an internationally-recognized health services researcher with expertise in palliative care. Her co-mentor is Dr. Edward Marcantonio, a geriatrician and internationallyrenowned clinical investigator in aging research. To complement the extensive expertise of Drs. Keating and Marcantonio, Dr. Wachterman has worked closely with them to carefully select a group of talented local advisors to provide additional knowledge and experience in qualitative research, decision science, nephrology, and biostatistics. She has also enlisted the support of a Steering Committee of nationally-known leaders with expertise relevant to her proposal. Overall, Dr. Wachterman will benefit greatly from working in Harvard's vibrant research community, which will provide her with skilled mentorship and support as she prepares to embark on her career as an independent investigator.

 描述（由申请人提供）：70 岁及以上的人是终末期肾病 (ESRD) 患者中增长最快的群体 研究表明，由于沟通不畅和对选择缺乏了解，有关开始透析的决策受到影响。一些小型研究表明，与不进行透析的保守治疗相比，透析可能会延长老年人的预期寿命，但可能会降低生活质量，但人们对老年人的预期效果知之甚少。此外，尽管透析开始的选择涉及透析潜在的寿命延长和保守治疗潜在的更好生活质量之间的一系列困难权衡，对患者、家庭和临床医生对这一决策过程的看法的研究很少，而且很少有资源来促进反映患者价值观和知情治疗偏好的决策。该提案具有以下三个相互关联和相关的内容。解决这些挑战的补充目标透析决策： 1) 定义 70 岁及以上患有 ESRD 的成年人在开始透析之前和之后的功能状态和认知功能轨迹，与未接受透析的成年人的轨迹进行比较 2) 探索关于开始透析的决定的观点。 （相对于最大限度的保守管理）针对 70 岁及以上的成年人、他们的家人和精英 3) 开发并试点测试决策辅助工具。 针对具有决策能力的即将发生 ESRD 的老年患者及其家人，旨在提高有关透析和保守治疗选择的知识，并提高个人价值观和治疗偏好的清晰度。第一个项目是使用全国代表性的纵向调查数据进行定量分析。来自健康与退休研究，与医疗保险索赔相关。第二个项目对处于决策过程不同阶段（决定透析之前和之后）的患者、家庭成员和战士进行定性半结构化访谈。利用从目标 1 和 2 中获得的知识，专门为预计在 12 个月内需要透析的 70 岁及以上有决策能力的成年人设计决策辅助工具，该辅助工具将在患者中进行试点测试 目标 3 的结果。将为决策辅助随机对照试验的 R01 提案提供初步数据。 K23 职业发展奖的总体目标是支持哈佛医学院姑息治疗医生和健康服务研究员 Melissa Wachterman 博士的早期职业生涯。Wachterman 博士是一位有前途的初级研究员，专门从事老年姑息治疗相关研究。她的职业目标是成为一名独立资助的临床医生研究员，开展研究，提高重病老年人及其家人的护理质量和以患者为中心的治疗决策。 Wachterman 之前对患有痴呆症等慢性疾病的老年人进行临终关怀的研究，以及她最近的工作探讨了老年患者对透析的看法以及肾科医生和患者在讨论预后时的沟通障碍。 该 K23 奖项将帮助 Wachterman 博士实现以下目标：1) 获得生物统计学和流行病学方面的高级培训，包括使用纵向全国代表性调查数据和行政数据的分析技能；2) 获得定性研究方法的高级培训；了解共同决策的理论框架并培养决策辅助开发和评估的技能；4) 发展成为一名研究者，以确保从职业发展奖成功过渡到独立的 R01 级资助。 为了实现这些目标，Wachterman 博士选择了一个指导团队，致力于她作为一名临床研究者的成功，利用她在哈佛医学院附属的三个领先学术医疗中心的联合任命：布莱根妇女医院、VA 波士顿医疗系统和她的主要导师是哈佛医学院医学与健康政策副教授 Nancy Keating 博士，也是一位国际知名的医疗服务研究员，在姑息治疗方面拥有专业知识。她的共同导师是 Edward 博士。 Marcantonio 是一位老年病学家和国际知名的衰老研究临床研究者，为了补充 Keating 和 Marcantonio 博士的广泛专业知识，Wachterman 博士与他们密切合作，精心挑选了一群才华横溢的当地顾问，以提供更多的定性知识和经验。她还获得了由具有与她的提案相关的专业知识的全国知名领导人组成的指导委员会的支持。总体而言，Wachterman 博士将从工作中受益匪浅。在哈佛大学充满活力的研究社区，这将为她提供熟练的指导和支持，帮助她准备开始作为一名独立调查员的职业生涯。