Effect of Medicare Reimbursement for Care Planning on End of Life Care among Patients with Alzheimer's Disease and Related Dementias: A Quasi-Experimental Study

项目摘要 阿尔茨海默病和阿尔茨海默病相关痴呆（AD/ADRD）是阿尔茨海默病的主要原因。 在美国，超过40%的在给定年份死亡的所有医疗保险患者患有AD/ADRD， AD/ADRD的死亡人数正在快速增长。患有AD/ADRD的垂死个体使用更积极的护理 在生命结束时，包括到医院的繁重过渡和疗效可疑的侵入性手术， 与那些没有认知障碍的人相比。提前护理计划（ACP），讨论和 在患者丧失能力的情况下，记录患者对护理目标的偏好， 减少积极治疗，增加临终关怀和姑息治疗的使用，特别是在AD/ADRD中 患者ACP存在障碍，并且没有研究检查ACP对寿命终止（EOL）的因果影响 使用国家数据对AD/ADRD患者进行治疗。本建议通过审查两个问题来解决这些差距 医疗保险报销政策的最新变化：2016年1月1日引入ACP账单代码， 并于2017年1月1日引入全面护理计划（CCP）计费代码。CCP目标 认知障碍患者，由几个强制性组成部分组成，包括开发、翻修 或审查预先护理计划。没有直接证据表明这两项补偿的效果 EOL治疗的变化;一般情况下或AD/ADRD患者中。该提案将利用医疗保险索赔数据 与多个补充数据源合并，以检查多个医生和患者相关因素 与ACP和CCP计费，并将创新性地应用两个准实验研究设计，分别 检查ACP和CCP计费对EOL护理支出和EOL护理的多项措施的因果影响 利用率通常用作全国AD/ADRD患者中EOL护理质量的指标。 将采用先进的统计学习技术，以进一步纠正偏差，提高 因果估计具体目的是：（1）识别相关的医生和患者特征 与ACP和CCP计费的AD/ADRD患者;（2）确定ACP计费对EOL护理的影响 使用回归不连续设计（RDD）在AD/ADRD患者中的使用和支出;（3） 确定CCP计费对AD/ADRD患者的EOL护理利用和支出的影响， 工具变量（IV）方法。影响：该项目将提供严格和关键的证据， 直接告知旨在改善AD/ADRD患者的EOL护理的有效政策。此外，该K 01 申请将使申请人成为少数几个在AD/ADRD、老年病学 和姑息治疗这将使她成为一名R 01资助的政策评估独立调查员 从而改善老年人群，特别是AD/ADRD患者的护理质量和生活质量。

PROJECT SUMMARY Alzheimer's disease and Alzheimer's Disease-related dementias (AD/ADRD) are a leading cause of death in the U.S. More than 40% of all Medicare patients who die in a given year have AD/ADRD, and the number of deaths from AD/ADRD are fast growing. Dying individuals with AD/ADRD use more aggressive care at end of life, including burdensome transitions to the hospital and invasive procedures of questionable benefit, compared to those with no cognitive impairment. Advance care planning (ACP), the process of discussing and recording patient preferences for goals of care in the event of patient losing capacity, has been shown to decrease aggressive treatment and increase use of hospice and palliative care, in particular among AD/ADRD patients. Barriers to ACP exist, and no research has examined the causal effect of ACP on end-of-life (EOL) care among AD/ADRD patients using national data. This proposal addresses these gaps by examining two recent changes in Medicare reimbursement policy: the introduction of ACP billing codes on January 1, 2016, and the introduction of comprehensive care planning (CCP) billing codes on January 1, 2017. The CCP targets cognitively impaired patients and consists of several mandated components, including development, revision or review of an Advance Care Plan. No direct evidence exists on the effect of these two reimbursement changes on EOL care; in general or among AD/ADRD patients. This proposal will utilize Medicare claims data merged with several supplementary data sources to examine multiple physician and patient factors associated with ACP and CCP billing, and will innovatively apply two quasi-experimental study designs to separately examine the causal effect of ACP and CCP billing on EOL care spending and multiple measures of EOL care utilization commonly used as indicators for quality of EOL care, among AD/ADRD patients nationwide. Advanced statistical learning techniques will be employed to further correct bias and improve precision of causal estimates. The Specific Aims are: (1) To identify the physician and patient characteristics associated with ACP and CCP billing for AD/ADRD patients; (2) To determine the effect of ACP billing on EOL care utilization and spending among AD/ADRD patients using a Regression Discontinuity Design (RDD); (3) To determine the effect of CCP billing on EOL care utilization and spending among AD/ADRD patients using an Instrumental Variables (IV) approach. IMPACT: This project will provide rigorous and critical evidence to directly inform effective policies targeted at improving EOL care for AD/ADRD patients. Further, this K01 application will establish the applicant as one the few health economists with expertise in AD/ADRD, geriatrics and palliative care. It will prepare her to become an R01-funded independent investigator in policy evaluations that lead to improved quality of care and quality of life for the aging population, in particular AD/ADRD patients.