End of Life Preferences and Healthcare Resource Use in Heart Failure Patients

简介(申请人提供)：邓雷博士是一名心脏病专家，专门从事心力衰竭(HF)患者的护理。她的长期目标是成为心力衰竭领域的独立健康服务和成果研究人员。她的短期目标是加强她的研究专长，增加新的技能，熟练掌握进行这类研究所需的工具。她在K23期间的培训计划的主要组成部分包括： *通过执行以下操作来增加她现有的技能： O通过课程学习增进卫生服务研究知识 O通过课程和实践掌握先进的数据分析技术 O扩大她对成果研究人员可用资源的了解 O发展生命末期和调查研究内容方面的专门知识 *通过在国家会议上介绍她的工作，申请参加早期职业委员会，以及与保健服务和成果研究方面的内部和外部专家合作，促进现有的和发展新的合作关系。 *发表影响巨大的成果：邓雷博士将发表5篇由拟议目标产生的资深作者论文，并至少与他人合著至少8篇证明成功合作的证据的论文 *获得RO1级资金：邓利博士将在获奖的第3年和第5年提交RO1提案 邓雷博士高度致力于在K23获奖期间成功过渡到一名独立的临床研究员。获得这一奖项对她实现自己的目标至关重要。 环境梅奥诊所长期致力于以患者为中心的医学和以患者为中心的研究。通过其全面的基础设施，梅奥诊所致力于并高度有能力培训内科研究人员，他们将成为心血管研究的未来领导者。梅奥诊所已将医疗服务和成果研究确定为一个迫切需要的领域和机构优先事项，这一点从该提案的导师V ronique Roger博士领导的医疗保健交付科学中心最近的发展中可见一斑。邓雷博士已经组建了一个由资深专家和经验丰富的导师组成的职业咨询委员会，他们完全致力于在K23获奖期内将她发展成为一名独立的临床调查员。最后，这些研究将在罗切斯特流行病学项目(REP)的支持下进行，该项目为执行本文提出的基于社区的卫生服务研究提供了一个独特的、成熟的框架。总之，制度环境和指导团队将确保邓雷博士成功地过渡到健康服务和结果研究的独立职业生涯。 研究背景：晚期心力衰竭患者的医疗资源利用率很高，包括反复住院，这对他们的生活质量产生了不利的影响，是一个主要的公共卫生问题。然而，尚不清楚生命末期患者的偏好和提前护理计划如何导致晚期心力衰竭患者医疗资源使用的差异。我们将通过拟议的研究来解决这些知识差距。具体目标：首先，我们将检查生命末期的医疗保健利用率，以及心衰类型(HFpEF，HFrEF)、虚弱以及姑息治疗和临终关怀服务的使用(目标1)可能如何影响它。下一步，我们将调查包括患者-提供者关于生命结束的对话在内的提前护理计划发生的频率(目标2)。最后，我们将确定提前护理计划和患者偏好是否会导致医疗资源使用的差异，包括住院(目标3)。研究设计和结果衡量：研究将在代表的主持下在明尼苏达州奥姆斯特德县进行。首先，在2003-2012年间以人群为基础的心力衰竭患者队列中，他们前瞻性地加入了这项提案的导师的研究，我们将检查死亡患者在生命的最后6个月内的医疗资源利用情况(住院、门诊和急诊科就诊)。使用考虑重复事件的Andersen-Gill模型，将根据HF类型(HFpEF与HFrEF)和脆弱程度来检查生命末期住院的风险，并调整潜在的混杂因素。还将研究接受姑息药物咨询和临终关怀服务的人在医疗保健使用方面的差异。其次，我们将前瞻性地招募连续入院的奥姆斯特县居民，通过面对面的问卷调查，评估他们的临终偏好和参与提前护理计划，并比较心力衰竭类型和脆弱程度的差异。最后，将跟踪登记的患者，并使用Andersen-Gill模型确定生命结束偏好和医疗资源使用之间的关联。潜在的公共卫生贡献：关于晚期心力衰竭患者的生命末期偏好及其与资源利用的关联的数据缺乏。拟议的目标将解决这些关键的知识差距，从而告知我们在护理心力衰竭患者方面的潜在差异，这些差异可能会干扰共同的决策过程，如果得到改善，可能会减少住院人数并改善患者与NHLBI使命的关系：这些研究旨在确定正确评估和治疗心力衰竭患者的方法，以便他们能够根据NHLBI使命声明过上更有成就感的生活。与候选人的职业目标的关系：拟议的研究将提供必要的高级接触，以人群为基础的健康服务研究在HF的表现，并将为候选人在HF健康服务和结果研究中建立职业生涯奠定基础。

DESCRIPTION (provided by applicant): Dr. Dunlay is a cardiologist specializing in the care of patients with heart failure (HF). Her long term goal is to become an independent health services and outcomes researcher in the field of HF. Her short term goal is to strengthen her research expertise and add new skills becoming proficient in the tools necessary to perform this type of research. Key components of her training plan during the K23 period include: * Adding to her existing skill set by doing the following: o Enhancing health services research knowledge through coursework o Mastering use of advanced data analysis techniques through coursework and practice o Expanding her knowledge of resources available to outcomes researchers o Developing end of life and survey research content expertise * Fostering existing and developing new collaborative relationships by presenting her work at national conferences, applying for participation in Early Career Committees, and working with internal and external experts in health services and outcomes research. * Publishing high impact results: Dr. Dunlay will publish 5 senior author papers resulting from the proposed aims and be a co-author on at least 8 additional papers demonstrating evidence of successful collaboration * Obtain RO1 level funding: Dr. Dunlay will submit RO1 proposals during the 3rd and 5th years of the award Dr. Dunlay is highly committed to making the successful transition to an independent clinical investigator during the K23 award period. The receipt of this award is critical to her attaining he goals. ENVIRONMENT The Mayo Clinic has a longstanding dedication to patient-centered medicine and patient-oriented research. Through its comprehensive infrastructure, the Mayo Clinic is both committed and highly capable of training physician investigators who will become future leaders in cardiovascular research. The Mayo Clinic has identified health services and outcomes research as an area of critical need and an institutional priority, as evidenced by the recent development of the Center for the Science of Healthcare Delivery, directed by Dr. V ronique Roger, mentor of this proposal. Dr. Dunlay has assembled a Career Advisory Committee of established experts and experienced mentors who are fully committed to her development into an independent clinical investigator during the K23 award period. Finally, these studies will be conducted under the auspices of the Rochester Epidemiology Project (REP), which provide a unique well-established framework for the performance of community-based health services research such as is being proposed herein. In summary, the institutional environment and mentoring team will ensure Dr. Dunlay's successful transition toward an independent career in health services and outcomes research. RESEARCH Background: Patients with advanced HF have high healthcare resource utilization including repeated hospitalizations that adversely affect their quality of life and are a major public health problem. However, it is unknown how end of life patient preferences and advance care planning contribute to differences in healthcare resource use in advanced HF. We will address these gaps in knowledge through the proposed studies. Specific Aims: First, we will examine healthcare utilization at the end of life and how it may be impacted by the type of HF (HFpEF, HFrEF), frailty, and use of palliative care and hospice services (Aim 1). Next, we will investigate how often advance care planning including patient-provider conversations regarding end of life occur (Aim 2). Finally, we will determine whether advance care planning and patient preferences contribute to differences in healthcare resource use, including hospitalizations (Aim 3). Study Design and Outcome Measures: The studies will be conducted in Olmsted County, MN under the auspices of the REP. First, among a population-based cohort of patients with HF who were prospectively enrolled into a study of the mentor of this proposal from 2003-2012, we will examine healthcare resource utilization (hospitalizations, outpatient and emergency department visits) in the last 6 months of life among those who died. Using Andersen-Gill models which account for repeated events, the risk of hospitalization at the end of life will be examined by type of HF (HFpEF vs. HFrEF) and frailty, adjusting for potential confounders. Differences in healthcare use among those who received palliative medicine consultation and hospice services will also be examined. Second, we will prospectively recruit consecutive Olmsted County residents hospitalized with HF and assess their end of life preferences and involvement in advance care planning using a face-to-face questionnaire and compare differences by type of HF and frailty. Finally, the enrolled patients will be followed and the association between end of life preferences and healthcare resource use will be determined using Andersen-Gill models. Potential Public Health Contribution: Data on end of life preferences in advanced HF and their association with resource utilization are lacking. The proposed aims will address these critical gaps in knowledge, thereby informing us on potential disparities in the care of HF patients that may be interfering with the shared decision- making process and, if improved, may lead to a reduction in hospitalizations and improved patient satisfaction Relationship to the NHLBI Mission: These studies aim to determine ways to properly assess and treat patients with HF so that they can live more fulfilling lives, in alignment with th NHLBI mission statement. Relationship to the Career Goals of the Candidate: The proposed studies will provide necessary advanced exposure to the performance of population-based health services research in HF and will be the foundation for the candidate to establish a career in HF health services and outcomes research.