Investigating Multi-Level Determinants of Racial/Ethnic Disparities in Quality of End-of-Life Care for Veterans

背景：种族/民族差异在退伍军人管理局的医疗保健系统中有很好的记录，然而，很少有记录 在临终关怀(EOL)领域已知。我们的初步工作表明，存在大型和 不同种族/民族的家庭对退伍军人接受的护理质量的看法存在显著差异 家庭在EOL，尽管同样使用临终关怀和姑息治疗服务。这些发现说明了有必要 确定退伍军人医疗中心(VAMC)的其他护理流程和组织功能，这些流程和组织功能可能 解释我们观察到的差异。少数族裔更倾向于延年益寿、集中精力 措施接近停产，与非停产措施相比，可能更有可能经历繁重的过渡 少数族裔。这些护理模式可能导致患者对护理的总体不满， 他们的家庭；然而，退伍军人中这些关系的性质尚不清楚。越来越多的文学作品也 提示护理的组织--医疗机构的一个可修改的特征--可能会起到 在缓和种族/族裔差距方面的关键作用，但尚未在终生关怀的背景下加以探讨。 具体目标：本项目的具体目标是：1)检查EOL护理模式，包括负担 过渡和临终关怀，将少数族裔与非少数族裔退伍军人进行比较；以及 描述少数民族和非少数民族退伍军人所在的VAMC的组织护理特点 在EOL得到照顾；2)确定观察到的种族/民族在家庭观念上的差异程度 EOL护理质量与EOL护理模式和护理组织的可修改方面相关联， 包括护士人员配备、护士工作环境和护理人员的种族/民族多样性；以及3)探索 少数民族和非少数民族退伍军人丧亲家属对影响因素的看法 影响EOL护理质量的因素，包括EOL护理模式和护理。 对退伍军人健康的意义和相关性：随着退伍军人人口年龄和年龄的不断增长 多样性，更多地关注EOL的护理将成为当务之急。目前，缺乏证据来指导 在VAMC中，为文化量身定制、以退伍军人和家庭为中心的EOL护理。 方法：我们将采用并行三角测量，使用多种VA的混合方法研究设计 2011-2015财年(FY)间收集的次要数据来源。主要数据来源包括： 临床数据仓库(CDW)、退伍军人护理结果数据库(VANOD)和丧偶家属 调查(BFS)-一个有效的工具，由失去亲人的退伍军人家属完成。样本 将包括研究期间全国142个退伍军人医疗中心(n=~46,000)的几乎所有住院死亡病例 句号。其中近60%的死者(n=约25,000人)可获得BFS答复。多层次物流 回归模型将被用来检验临终关怀模式和VAMC的主要影响 组织因素对EOL的种族/民族差异家庭对EOL护理质量的认知以及 患者层面和设施层面因素之间潜在的跨层面相互作用。一种改进的扎根理论 为实现研究的质的目标，将采用研究方法。 创新：没有一项研究，无论是在退伍军人事务部内外，都没有检查过患者因素的交集， 护理的组织，以及EOL护理质量的种族/民族差异。这项研究还将包括 迄今为止最大规模的种族/少数族裔家庭成员对 EOL的退伍军人。 预期结果：通过确定退伍军人和设施级特征的相对重要性 有助于发展种族/民族差异，以满足VAMC接受的EOL护理，这 研究将立即提供可操作的知识，并为发展 干预努力实现公平和以退伍军人为中心的医疗体系。

Background: Racial/ethnic disparities are well-documented in the VA healthcare system, however, little is known in the area of end-of-life (EOL) care. Our preliminary work suggests the presence of large and significant disparities by race/ethnicity in family perceptions of the quality of care received by the Veteran and family at EOL, despite equal use of hospice and palliative care services. These findings illuminate the need to identify other care processes as well as organizational features of VA Medical Centers (VAMCs) that may explain the differences we observe. Racial/ethnic minorities are more likely to prefer life-prolonging, intensive measures near EOL and may be more likely to experience burdensome transitions as compared to non- minorities. These care patterns may contribute to overall dissatisfaction with care when rated by patients and their families; however, the nature of these relationships in VA is not known. A growing body of literature also suggests that the organization of nursing care- a modifiable characteristic of healthcare facilities - may play a key role in moderating racial/ethnic disparities, but has not been explored in the context of EOL care. Specific Aims: The specific aims of this project are to: 1) examine EOL care patterns, including burdensome transitions and intensive EOL care, comparing racial/ethnic minority to non-minority Veteran populations; and to describe organizational nursing characteristics of VAMCs where minority and non-minority Veterans are cared for at the EOL; 2) identify the extent to which observed racial/ethnic differences in family perceptions of EOL care quality are associated with EOL care patterns and modifiable aspects of nursing care organization, including nurse staffing, the nurse work environment, and racial/ethnic diversity of nursing staff; and 3) explore the perspectives of bereaved family members of racial/ethnic minority and non-minority Veterans on factors that influence quality of EOL care, including EOL care patterns and nursing care. Significance and Relevance to Veterans' Health: As the Veteran population continues to grow in age and diversity, greater focus on care at EOL will become imperative. Currently, there is a dearth of evidence to guide culturally-tailored, Veteran-and family-centered EOL care in VAMCs. Methodology: We will employ a concurrent triangulation, mixed methods study design using a variety of VA secondary data sources collected between Fiscal Years (FY) 2011-2015. Major data sources include: the Clinical Data Warehouse (CDW), the VA Nursing Outcomes Database (VANOD), and the Bereaved Family Survey (BFS) - a well-validated instrument completed by bereaved family members of Veterans. The sample will include nearly all inpatient deaths in 142 VA Medical Centers nationally (n=~46,000) during the study period. BFS responses are available for nearly 60% of these decedents (n=~25,000). Multi-level logistic regression models will be used to examine the main effects of end-of-life care patterns and VAMC organizational factors on EOL racial/ethnic disparities in family perceptions of EOL care quality, as well as any potential cross-level interactions between patient- and facility- level factors. A modified grounded theory approach will be used to achieve the qualitative aim of the study. Innovation: No study, within or outside of VA, has examined the intersection of patient factors, the organization of nursing care, and racial/ethnic disparities in quality of EOL care. This study will also include the largest qualitative assessment to date of racial/ethnic minority family members' perceptions of care received by Veterans at EOL. Expected Results: By identifying the relative importance of Veteran- and facility-level characteristics that contribute to the development of racial/ethnic disparities in satisfaction with EOL care received in VAMCs, this study will provide immediate actionable knowledge, as well as foundational evidence for the development of intervention efforts to achieve an equitable and Veteran-centered healthcare system.