Racial/Ethnic Differences in Palliative Care Services and Potentially Avoidable Hospitalizations at End-of-Life in Nursing Homes Nationwide

在任何一天，大约有160万美国人生活在全国的养老院（NHs）和90%的美国人。 居民年龄≥ 65岁。在过去的二十年里， 种族/少数民族NH居民和非拉丁裔白色NH居民减少。少数种族/族裔 通常居住在低收入社区的NHS中，这些社区资源贫乏， 在乎COVID-19凸显了NH少数种族/民族居民的脆弱性增加。之前 COVID-19，估计美国所有死亡病例中有25%发生在NH，约44%发生在非临终关怀 NH居民在生命的最后30天内经历了住院治疗。种族/少数民族居民 与非拉丁裔白色NH居民相比，住院率增加。许多这些 住院是可以避免的。姑息治疗在提供高质量的临终关怀方面至关重要， 缓解症状并为患者和护理人员提供支持;然而，姑息治疗在 很多nh在初步工作中，使用2017年随机抽样的全国分层调查数据（n = 10）， 892)来自生命末期感染管理和姑息治疗研究（SIMP-EL; R 01 NR 013687; Stone PI和Mentor），我发现NH临终关怀服务存在很大差异。然而，健康 NH姑息治疗服务的差异尚未研究。此外，尚不清楚NH的变化如何 姑息治疗服务与临终时可能避免的住院治疗有关。指导 Gelberg-Andersen的弱势群体行为模型，在我将讨论的拟议研究中， 通过使用多个数据源进行二次、横断面分析（即，SIMP-EL 调查;来自最小数据集3.0的NH居民评估;来自Medicare的医院索赔数据 提供商和分析审查;认证和调查提供商提供的NH设施特征增强 报告;以及来自地区卫生资源档案的县级数据）。具体来说，我的目标是：1） 描述全国范围内NHS提供的姑息治疗服务，并确定不同人群的差异 服务（即，少数种族/族裔的比例）和2）确定姑息治疗服务之间的关联 和潜在可避免的住院治疗在生命结束时由NH居民的种族/民族。目标1是NH水平 分析和目标2是个人居民水平分析。这项研究与国家研究所的 临终关怀护理研究的优先领域和姑息治疗研究，以改善姑息治疗策略 对于患有严重疾病的个人和家庭。为了促进这项研究，申请人将建立她的知识 姑息治疗，定量研究方法和种族/民族健康差距的技能。作为一个拉丁裔前- 博士生与美国国立卫生研究院资助的跨学科的专门指导 研究人员，哥伦比亚大学资源丰富的环境，并在回应PA-20-251，收到 该研究金将有助于增加从事卫生相关研究的个人的多样性。

On any day, approximately 1.6 million Americans live in the nation’s nursing homes (NHs) and 90% of the residents are ≥ 65 years old. In the last two decades, there has been an increase in the proportion of racial/ethnic minority NH residents and a decrease in non-Latino White NH residents. Racial/ethnic minorities often reside in NHs situated in low-income communities that are poorly resourced and provide low quality of care. COVID-19 has highlighted the increased vulnerability of racial/ethnic minority NH residents. Prior to COVID-19, an estimated 25% of all deaths in the US occurred in NHs and approximately 44% of non-hospice NH residents experienced hospitalizations during the last 30 days of life. Racial/ethnic minority NH residents experience increased hospitalizations compared to non-Latino White NH residents. Many of these hospitalizations are potentially avoidable. Palliative care is essential in providing high quality end-of-life care by alleviating symptoms and providing support to patients and caregivers; yet, palliative care is suboptimal in many NHs. In preliminary work using 2017 data from the randomly sampled, national, stratified survey (n = 892) from the Study of Infection Management and Palliative Care at the End-of-Life (SIMP-EL; R01 NR013687; Stone PI and mentor), I found wide variation in NH palliative care services at the end-of-life. However, health disparities in NH palliative care services has not been studied. Furthermore, it is unknown how variations in NH palliative care services are associated with potentially avoidable hospitalizations at the end-of-life. Guided by the Gelberg-Andersen’s Behavioral Model for Vulnerable Populations, in the proposed study I will address these gaps by conducting a secondary, cross-sectional analysis using multiple data sources (i.e., the SIMP-EL survey; NH resident assessments from the Minimum Data Set 3.0; hospital claims data from the Medicare Provider and Analysis Review; NH facility characteristics from the Certification and Survey Provider Enhanced Reporting; and county level data from the Area Health Resources Files). Specifically, my aims are to: 1) Describe palliative care services provided in NHs across the nation and identify differences by population served (i.e., proportion of racial/ethnic minorities) and 2) Identify associations between palliative care services and potentially avoidable hospitalizations at the end-of-life by NH resident’s race/ethnicity. Aim 1 is a NH level analysis and Aim 2 is an individual resident level analysis. This research aligns with the National Institute of Nursing Research priority area of End-of-Life and Palliative Care Research to improve palliative care strategies for individuals and families with serious illness. To facilitate this research, the applicant will build her knowledge and skills in palliative care, quantitative research methods, and racial/ethnic health disparities. As a Latina pre- doctoral student with the dedicated mentorship of National Institutes of Health-funded interdisciplinary researchers, the resource-rich environment of Columbia University, and in response to PA-20-251, receipt of this fellowship will contribute to increasing the diversity of individuals conducting health-related research.