Impact of federal policies on disparities at the end of life care among nursing home residents with Alzheimer's diseases or related dementia

联邦政策对患有阿尔茨海默病或相关痴呆症的疗养院居民临终关怀差异的影响

• 批准号: 10729733
• 负责人: Lichuan Ye
• 金额: $ 58.63万
• 依托单位: NORTHEASTERN UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-08-15 至 2026-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10729733
• 关键词: Advocacy; Affect; Alzheimer' s disease patient; Alzheimer' s disease related dementia; American; Assessment tool; Black race; Caring; Categories; Cessation of life; Characteristics; Classification; Clinical; Communities; Complex; Data; Data Set; Data Sources; Dementia; Disparity; Elderly; Emergency department visit; Enteral Feeding; Equity; Goals; Health; Hospice Care; Hospice Programs; Hospitalization; IV Fluid; Individual; Insurance Carriers; Intensive Care Units; Interruption; Intervention; Length; Life; Location; Machine Learning; Measures; Medicare; Methods; Nursing Homes; Pathway Analysis; Patient Care; Patient Selection; Patients; Pharmaceutical Preparations; Phenotype; Police; Policies; Policy Maker; Prognosis; Provider; Quality of life; Race; Reporting; Risk; Series; Subgroup; Syndrome; Time; Vulnerable Populations; acute care; beneficiary; care providers; curative treatments; end of life; end of life care; experience; federal policy; health equity; health equity promotion; high risk; high risk population; hospice environment; improved; insight; multiple chronic conditions; pain reduction; racial disparity

Project Summary Racial disparities in end-of-life (EOL) care continue to persist in nursing home (NH) residents with Alzheimer’s disease and related dementia (ADRD). Recent studies reported that black NH residents with dementia were more likely to receive aggressive EOL care, including hospitalizations, ER visits, feeding tubes and aggressive medication therapy, compared to Whites. ADRD is a progressive, life-limiting syndrome without a curative treatment. Hence, hospice care is preferable for older adults with ADRD during EOL because it prioritizes comfort and quality of life by reducing pain and suffering. Medicare is the primary insurer of patients with ADRD and covers hospice for all with a 6-months or shorter prognosis. As about 90% of older Americans with ADRD are placed in NHs before death, it is critically important for Medicare policy makers to understand contemporary characteristics of racial disparities in hospice care in NHs in order to implement efficient policies to promote health equity. Recently, there raised concerns about fraudulent/inappropriate patient selection practices that favored long-stay patients, particularly ADRD patients, because patients with longer hospice stays generated greater profits for hospices. To discourage hospice selection for long-stay patients, Medicare launched the 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act to mandate auditing targeted hospices with high proportion of patient staying longer than 180 days. It remains unaddressed how racial disparities change with implementing IMPACT in NH residents with ADRD. The project’s overall goal is to improve EOL health equity for NH residents with ADRD. The aims for this R01 proposal are to identify the effects of IMPACT on racial disparities in hospice care in NH residents with ADRD, and to characterize subgroups that are most likely to experience inadequate hospice care. The primary hypothesis is that racial disparities in EOL care increased persistently after IMPACT was implemented. We will employ mixed methods to accomplish the following aims (A) and hypotheses (H): A1. To examine impacts of IMPACT on racial disparities in hospice care in NH residents with ADRD. A2. To characterize phenotypes of NH residents with ADRD based on multimorbidity who have high risks for very short or very long hospice care, and compare these phenotypes between Black and White residents. A3. To obtain perspectives of care providers in NHs about how hospice polices may influence hospice care referrals among residents with ADRD. An expert panel of clinical advisors will identify barriers to hospice care referrals, and potential mechanisms through which Medicare policies could reduce them. This study will evaluate Medicare policy on racial disparities in hospice care among a very vulnerable population: older adults with ADRD who reside in NHs. Results will also identify subgroups of these individuals at high risk of inadequate hospice stays. Findings will support clinicians with insight about how interventions to reduce racial disparities and improve health equity can be targeted to individuals in high-risk groups.

项目概要 患有阿尔茨海默病的疗养院 (NH) 居民在临终 (EOL) 护理方面的种族差异仍然存在 最近的研究报告称，新罕布什尔州黑人居民患有痴呆症。 更有可能接受积极的 EOL 护理，包括住院、急诊室就诊、饲管和积极的治疗 与白人相比，药物治疗是一种进行性、限制生命的综合征，没有治愈方法。 因此，临终关怀对于患有 ADRD 的老年人来说更可取，因为它优先考虑。 通过减少疼痛和痛苦来提高舒适度和生活质量。 Medicare 是患者的主要保险公司。 ADRD 并为所有预后为 6 个月或更短的美国人提供临终关怀服务，大约 90% 的美国老年人患有此病。 ADRD 在死亡前被安置在 NH 中，医疗保险政策制定者了解这一点至关重要 NH 临终关怀种族差异的当代特征，以便实施有效的政策 最近，人们对欺诈/不当的患者选择表示担忧。 这种做法有利于长期住院的患者，特别是 ADRD 患者，因为临终关怀时间较长的患者 住院为临终关怀机构带来了更大的利润，为了阻止长期住院患者选择临终关怀机构，医疗保险计划制定了这一政策。 推出 2014 年改善医疗保险急性护理转型 (IMPACT) 法案以强制进行审计 住院时间超过 180 天的患者比例较高的目标临终关怀机构如何解决仍待解决。 在患有 ADRD 的新罕布什尔州居民中实施 IMPACT 后，种族差异会发生变化。 该项目的总体目标是改善患有 ADRD 的 NH 居民的 EOL 健康公平性。 提案旨在确定 IMPACT 对患有 ADRD 的新罕布什尔州居民临终关怀中种族差异的影响， 并描述最有可能得不到充分临终关怀的亚群体的特征。 假设实施 IMPACT 后，EOL 护理中的种族差异持续增加。 采用混合方法来实现以下目标（A）和假设（H）： A1. 研究 IMPACT 对患有 ADRD 的新罕布什尔州居民临终关怀中种族差异的影响。 A2. 根据患有 ADRD 的高风险的 NH 居民的表型特征 非常短期或非常长期的临终关怀，并比较黑人和白人居民之间的这些表型。 A3. 了解新罕布什尔州护理人员对临终关怀政策如何影响临终关怀的看法 临床顾问专家小组将确定患有 ADRD 的居民的护理转介。 临终关怀转诊，以及医疗保险政策可以减少转诊的潜在机制。 这项研究将评估医疗保险政策对非常弱势群体临终关怀中种族差异的影响 人群：居住在 NH 中的患有 ADRD 的老年人 结果还将确定这些人的亚组。 临终关怀住院的风险很高，调查结果将提供有关如何干预的见解。 减少种族差异和改善健康公平可以针对高风险群体中的个人。