Identifying barriers, facilitators and outcomes of Advanced Care Planning conversations with Medicare patients

确定与 Medicare 患者进行高级护理计划对话的障碍、促进因素和结果

• 批准号: 9763016
• 负责人: Joel S. Weissman
• 金额: $ 47.54万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-09-11 至 2021-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9763016
• 关键词: Address; Admission activity; Adoption; Advance Care Planning; American; Atlases; Bereavement; Caregivers; Caring; Case Study; Cessation of life; Chronic Obstructive Airway Disease; Clinical; Data; Dementia; Diagnostic; Effectiveness; Elderly; Environmental air flow; Expenditure; Face; Fee-for-Service Plans; Focus Groups; Frequencies; Geography; Health Expenditures; Health system; Heart failure; Hospice Care; Hospital Referrals; Hospitals; Improve Access; Incidence; Individual; Institute of Medicine (U.S.); Integrated Health Care Systems; Intensive Care; Intensive Care Units; Intervention; Interview; Kidney Failure; Life; Life Expectancy; Location; Lung diseases; Malignant Neoplasms; Medical; Medicare; Medicare claim; Mental Health; Methods; Neurodegenerative Disorders; Nurses; Nursing Specialties; Operative Surgical Procedures; Outcome; Palliative Care; Patient Care; Patients; Pattern; Physicians; Policies; Population; Prevalence; Prospective cohort; Qualitative Methods; Quality of Care; Recommendation; Research; Research Personnel; Resources; Resuscitation; Services; Structure; System; Technology; Terminally Ill; Time; Time trend; United States Centers for Medicare and Medicaid Services; Vacuum; care costs; care delivery; care outcomes; chemotherapy; clinical practice; contextual factors; end of life; end of life care; health organization; hospice environment; improved; medical specialties; older patient; palliative; preference; research study; surrogate decision maker; theories; trend; uptake; urban residence; virtual; willingness

Project Summary/Abstract Although the use of palliative and hospice care for terminally ill Medicare patients is growing, large numbers of Americans die following intensive, non-curative, burdensome treatments. Available evidence suggests that advanced care planning (ACP) discussions are associated with less aggressive end-of-life (EOL) care, greater concordance between the care patients prefer and the care they receive, and perhaps improved bereavement outcomes for caregivers. However, national data on the uptake and impact of ACP are lacking. As a result of a new policy from the Centers for Medicare & Medicaid Services (CMS), effective January 1, 2016, clinicians may now bill for having ACP discussions with their patients. This provides an unprecedented opportunity to study the use and impact of these discussions on a national population basis. Importantly, these services are reimbursable whether they are provided by physicians or nurses in any setting. The proposed study will use both quantitative and qualitative methods to provide a unique scientific examination of the use of ACP discussions and their impact on the intensity and outcomes of care received by seriously ill patients nearing the end of life. We propose the following aims: Aim 1) To identify trends in use and factors associated with Medicare ACP discussions. Using Medicare claims files, we will examine the number and types of patients who have ACP discussions documented by their clinicians, factors associated with ACP use, and trends over time in ACP uptake. Aim 2) To examine the impact of ACP discussions on EOL intensity among seriously ill patients. Using Medicare claims files, we will build a prospective cohort of seriously ill patients and examine the effect of ACP conversations on patients' EOL intensity. Aim 3) To identify barriers and facilitators of conducting ACP discussions in clinical settings. Using qualitative methods (case studies, focus groups, semi-structured interviews), we will examine patients', clinicians', and other stakeholders' perceived barriers and facilitators to the use of ACP, as well as explore implications of ACP conversations with respect to clinical workflow. It is hoped that by further understanding utilization patterns of ACP use and accompanying barriers and facilitators to implementation may influence patient care. We expect that the findings of the proposed analyses will serve to advise health systems and policymakers on how best to direct resources and address potential inequities relating to ACP conversations and, more broadly, inform the viability of targeting ACP as a primary vehicle for change, as opposed to other aspects of the EOL care delivery system.

项目摘要/摘要 尽管使用姑息治疗和临终关怀护理用于绝症患者，但大量 美国人在密集，非策略，繁重的治疗中死亡。可用证据表明 高级护理计划（ACP）讨论与较不积极的寿命（EOL）护理相关，更大 护理患者喜欢和他们接受的护理之间的一致性，也许改善了丧亲 护理人员的成果。但是，缺乏有关ACP的吸收和影响的国家数据。 由于Medicare＆Medicaid Services（CMS）的新政策，从1月1日起 2016年，临床医生现在可能会对与患者进行ACP讨论的费用。这提供了前所未有的 在国家人口基础上研究这些讨论的使用和影响的机会。重要的是，这些 无论是由医生还是护士在任何情况下提供的服务，都可以报销服务。 拟议的研究将同时使用定量和定性方法来提供独特的科学 检查ACP讨论的使用及其对收到的护理强度和结果的影响 认真生病的患者接近生命的尽头。我们提出以下目标： 目标1）确定使用趋势和与Medicare ACP讨论相关的因素。使用 Medicare索赔文件，我们将检查进行ACP讨论的患者的数量和类型 由其临床医生记录，与ACP使用相关的因素以及ACP吸收的趋势。 目标2）检查ACP讨论对重病患者的EOL强度的影响。 使用Medicare索赔文件，我们将建立一个预期的重病患者的队列，并检查 对患者EOL强度的ACP对话。 目标3）确定在临床环境中进行ACP讨论的障碍和促进者。使用 定性方法（案例研究，焦点小组，半结构化访谈），我们将检查患者的 临床医生和其他利益相关者的感知障碍和促进者的使用，并探索 ACP对话与临床工作流程的含义。 希望通过进一步了解ACP使用和伴随障碍的利用模式以及 促进者实施可能会影响患者护理。我们期望拟议的分析的发现 将为卫生系统和政策制定者提供有关如何最好地指导资源和解决潜力的建议 与ACP对话有关的不平等，更广泛地告知目标ACP作为主要的可行性 与EOL护理交付系统的其他方面相反，更改的车辆。