Impact of POLST Adoption and of Financial Incentives on Care Receipt and on Intensity of Care Preferences in Nursing Home Patients

POLST 采用和经济激励对疗养院患者护理接受和护理偏好强度的影响

• 批准号: 9884523
• 负责人: DAVID Scott ZINGMOND
• 金额: $ 18.67万
• 依托单位: UNIVERSITY OF CALIFORNIA LOS ANGELES
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-04-15 至 2022-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9884523
• 关键词: Adopted; Adoption; Advance Care Planning; Age-Years; Ambulatory Care; California; Caring; Cessation of life; Chronic Care; Chronically Ill; Clinic; Clinical; Collection; Communities; Critical Illness; Data; Data Set; Decision Making; Diagnosis; Dialysis procedure; Elderly; Elements; Enrollment; Evaluation; Fee-for-Service Plans; Funding; Goals; Health; Hospitalization; Hospitals; Impact evaluation; Incentives; Intervention; Life; Long-Term Care; Measures; Medical; Medical Technology; Medicare; Nursing Homes; Oregon; Outcome; Patient Preferences; Patients; Physicians; Policies; Provider; Quality of Care; Registries; Reporting; Standardization; Telephone; Time; Ventilator; base; care preference; catalyst; end of life; end of life care; financial incentive; hospice environment; innovation; payment; preference; public health relevance; response; tool

ABSTRACT Advance care planning (ACP), including end-of-life (EOL) discussions and decision-making, are important elements for the care of chronically and critically ill patients. Ideally, doctors would have conversations with patients with incurable, life-limiting illnesses about treatment options, based on the patient’s goals and values. These conversations cover how aggressively to treat an illness as well as the option eventually for hospice. These conversations ideally should happen long before a patient dies or becomes too ill to have these discussions. However, in many cases, ACP discussions between patients and providers do not occur. In response to this need for ACP, including EOL discussions and decision-making, some important changes have occurred. Nationally, a framework for standardizing patient preference forms – Physician Orders for Life Sustaining Treatment (POLST) or their equivalent – have been developed and introduced on a state-by-state basis. California adopted POLST in 2009 and began routinely collecting POLST as a supplement (Section S) to the Long-Term Care Minimum Data Set (MDS) for nursing home residents. Nationally, CMS began in January 2016 to reimburse providers to have ACP discussions, creating an incentive for providers to initiate, revisit, and report these discussions. The combination of these two separate policy interventions – state-by-state implementation of POLST and Medicare reimbursement for ACP discussions – allow for empiric evaluation of patient preferences and their impact (when collection is encouraged/facilitated) on care choices and outcomes. Using national nursing home data (MDS), California MDS Section S, Medicare enrollment data and FFS claims, and California all-payer hospital data (years 2011 to 2018), we propose the following aims and associated hypotheses for the evaluation of the impact of standardization and financial incentives related to ACP discussions in Medicare enrollees 65 years of age and older: 1. Assess the impact of POLST rollout on utilization of care at EOL and quality of care at the EOL among FFS Medicare patients in nursing homes nationally. 2. Assess the impact of Medicare FFS payment policy for ACP discussions on utilization of care at EOL and quality of care at the EOL among FFS Medicare patients in nursing homes nationally. 3. Assess the impact of Medicare payment policy for ACP discussions on POLST completion, patient preferences, and utilization of care at EOL and quality of care at the EOL in California nursing home residents enrolled in Medicare. This study will evaluate the policy impact on care for the elderly nationally and will leverage unique routinely collected POLST data from California to quantify the direct impact of physician incentives on patient preferences. Study results will be a catalyst for further innovation in ACP discussions and EOL planning.

抽象的 预先护理计划 (ACP)，包括临终 (EOL) 讨论和决策，非常重要 理想情况下，医生会与慢性病和危重病患者进行对话。 根据患者的目标和价值观，向患有无法治愈的、限制生命的疾病的患者提供治疗选择。 这些对话涵盖如何积极治疗疾病以及最终的临终关怀选择。 理想情况下，这些对话应该在患者死亡或病重而无法进行这些对话之前很久进行 然而，在许多情况下，患者和提供者之间不会进行 ACP 讨论。 为了响应 ACP 的这种需求，包括 EOL 讨论和决策，进行了一些重要的更改 在全国范围内，已经出现了标准化患者偏好表的框架——终身医生医嘱。 维持治疗 (POLST) 或同等治疗 – 已在各州制定和实施 加利福尼亚州于 2009 年采用 POLST，并开始定期重复 POLST 作为补充（S 节） CMS 开始于全国范围内针对疗养院居民的长期护理最低数据集 (MDS)。 2016 年 1 月，补偿提供商进行 ACP 讨论的费用，从而激励提供商发起、 重新访问并报告这些讨论。 这两种单独的政策干预措施的结合——各州实施 POLST 和 ACP 讨论的医疗保险报销 – 允许对患者偏好及其情况进行经验评估 （当鼓励/促进收集时）对使用国家疗养院的护理选择和结果的影响。 数据 (MDS)、加州 MDS S 部分、医疗保险登记数据和 FFS 索赔以及加州全付款人 根据医院数据（2011年至2018年），我们提出以下目标和相关假设： 评估与 Medicare 中 ACP 讨论相关的标准化和财务激励措施的影响 65 岁及以上的注册者： 1. 评估 POLST 的推出对 EOL 护理利用率和 EOL 护理质量的影响 全国疗养院的 FFS Medicare 患者。 2. 评估 Medicare FFS 支付政策对 ACP 讨论对 EOL 护理利用的影响 全国疗养院 FFS Medicare 患者的 EOL 护理质量。 3. 评估 ACP 讨论的 Medicare 支付政策对 POLST 完成、患者的影响 加州疗养院 EOL 时的偏好和护理利用以及 EOL 时的护理质量 参加医疗保险的居民。 这项研究将评估政策对全国老年人护理的影响，并将利用独特的常规 收集了来自加利福尼亚州的 POLST 数据，以量化医生激励措施对患者的直接影响 研究结果将成为 ACP 讨论和 EOL 规划进一步创新的催化剂。