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

调查退伍军人临终护理质量中种族/民族差异的多层次决定因素

• 批准号: 9669895
• 负责人: Ann Kutney Lee
• 金额: --
• 依托单位: PHILADELPHIA VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-04-01 至 2021-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9669895
• 关键词: Accounting; Achievement; Age; American; Area; Attenuated; Cardiopulmonary Resuscitation; Care given by nurses; Caring; Cessation of life; Characteristics; Clinical; Complex; Data; Data Sources; Databases; Development; Discipline of Nursing; Ensure; Ethnic Origin; Family; Family member; Foundations; Goals; Health; Health care facility; Healthcare; Healthcare Systems; Hispanics; Home environment; Hospice Care; Hospitalization; Hospitals; Inpatients; Intervention; Knowledge; Life; Link; Literature; Logistic Regressions; Measurement; Measures; Mechanical ventilation; Medical; Medical center; Methodology; Methods; Minority; Modeling; Nature; Nurses; Nursing Services; Nursing Staff; Office Nursing; Outcome; Palliative Care; Patient-Focused Outcomes; Patients; Patterns of Care; Perception; Performance; Play; Policies; Population; Process; Quality of Care; Race; Recommendation; Registered nurse; Reporting; Research; Research Design; Risk; Sampling; Services; Surveys; Veterans; Work; aggressive therapy; care systems; clinical data warehouse; design; disparity reduction; end of life; end of life care; ethnic difference; ethnic diversity; ethnic minority population; experience; health care quality; health disparity; hospice environment; improved; innovation; instrument; preference; professional atmosphere; programs; racial and ethnic; racial and ethnic disparities; racial disparity; response; satisfaction; standard of care; systematic review; theories; therapy development

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.

背景：在VA医疗保健系统中，种族/民族差异有很好的记录，但是， 在生命末期（EOL）护理领域中已知。我们的初步研究表明， 家庭对退伍军人所接受的护理质量的看法存在种族/民族的显著差异， 在EOL的家庭，尽管平等使用临终关怀和姑息治疗服务。这些发现说明， 确定其他护理流程以及VA医疗中心（VAMC）的组织特征， 解释我们观察到的差异。种族/少数民族更倾向于延长生命，密集 接近EOL的测量，与非测量相比， 少数群体这些护理模式可能会导致患者对护理的总体不满意， 他们的家庭;然而，这些关系在VA的性质是未知的。越来越多的文学作品 这表明，护理的组织-医疗机构的一个可修改的特征-可能会发挥作用， 在缓和种族/民族差异的关键作用，但尚未在终末期护理的背景下进行探讨。 具体目标：该项目的具体目标是：1）检查EOL护理模式，包括繁重的 过渡和强化EOL护理，将种族/少数民族与非少数民族退伍军人群体进行比较;以及 描述VAMC的组织护理特征，其中少数民族和非少数民族退伍军人是 2）确定在多大程度上观察到的种族/民族差异的家庭观念， 终末期护理质量与终末期护理模式和护理组织的可修改方面相关， 包括护理人员配置、护理工作环境和护理人员的种族/民族多样性; 3）探索 种族/少数民族和非少数民族退伍军人遗属对因素的看法 影响终末期护理质量的因素，包括终末期护理模式和护理。 退伍军人健康的意义和相关性：随着退伍军人人口年龄的不断增长， 多元化，更加注重护理在EOL将成为当务之急。目前，缺乏证据来指导 VAMC中文化定制的、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，混合方法研究设计，使用各种VA 2011-2015财年（FY）收集的二级数据来源。主要数据来源包括： 临床数据仓库（CDW），VA护理结果数据库（VANOD）和丧亲家庭 调查（BFS）-由退伍军人家属完成的经过充分验证的工具。样品 将包括研究期间全国142个VA医疗中心（n=~ 46，000）的几乎所有住院死亡病例 期近60%的死亡动物（n=~ 25，000）可获得BFS应答。多层次物流 回归模型将被用来研究临终关怀模式和VAMC的主要影响 组织因素对EOL种族/民族差异的家庭观念的EOL护理质量，以及任何 患者和机构层面因素之间潜在的跨层面相互作用。修正的扎根理论 方法将用于实现研究的质量目标。 创新：没有研究，内部或外部的VA，已经检查了病人因素的交叉点， 护理组织和终末期护理质量的种族/民族差异。这项研究还将包括 迄今为止，对少数种族/族裔家庭成员对所得到的照顾的看法进行了最大规模的定性评估， 退伍军人在EOL。 预期结果：通过确定退伍军人和设施一级特征的相对重要性， 在VAMC中接受的EOL护理的满意度方面， 研究将提供直接的可操作的知识，以及发展的基础证据， 干预努力，以实现公平和以退伍军人为中心的医疗保健系统。