Improving Care for Older Adults with Serious Illness

描述(由申请人提供)：本提案代表了一个五年的课程和研究计划，旨在促进我发展为一名以患者为导向的衰老研究的独立调查员。在五年的获奖期间，我将通过导师式的研究、正式的课程作业和自我指导的学习活动来扩大我的卫生服务研究培训和经验，并通过领导力和网络机会发展独立性。随着人口中年龄最大的群体的扩大，美国目前的医疗支出速度是不可持续的。医院服务占医疗保险成本的最大部分，其中大部分流向了特定的患者群体：患有严重疾病的老年人。地理区域在医院使用强度方面差异很大，一些人认为这代表着可自由支配的或不必要的基于医院的护理。以寿命、生活质量和满意度来衡量，增加支出也与更高的质量无关。了解哪些因素导致高危老年人不必要的住院，对于开发有效的、以患者为中心的护理的成功新模式至关重要。因此，我的研究目标是前瞻性地确定重病老年人面临HIH费用医院护理的风险，并为这些患者确定潜在可以避免的住院和留在社区的障碍。具体地说，我计划：(SA1)在我以前工作的基础上，使用死亡率跟踪设计，在健康和退休研究(HRS)队列中检查住院支出、住院人数和最后一年基于医院的高强度治疗的决定因素；(SA2)通过评估与医院支出、住院次数和治疗强度相关的因素，在一组与一年死亡风险相匹配的重病老年人队列中扩展我早期的发现；和(SA3)支持制定干预措施，通过对患者、照顾者和初级保健医生进行定性访谈，调查重病老年人多次住院的原因和院外管理障碍，减少高危老年人不必要的住院人数。拟议的工作使用区域、患者水平和索赔数据的创新组合来评估在这一人群中驱动治疗强度的因素；使用传统的死亡率跟踪研究设计和新的前瞻性分析技术检查结果；并采用混合方法从患者和家属那里了解哪些问题导致过度住院以及如何克服这些挑战。通过我目前的工作和未来的独立研究，我计划创建一个以患者为中心的干预措施，以减少重病老年人不必要的住院，并将我的工作转化为有效的医疗保健政策和临床计划。拟议的研究和职业发展计划是推进老年人护理的重要初步步骤，方法是改善面对严重疾病的医疗决策，并促进更好地将治疗与患者偏好相结合的政策。

DESCRIPTION (provided by applicant): This proposal represents a five-year curriculum and research plan designed to facilitate my development to an independent investigator in patient-oriented aging research. During the five years of the award, I will expand on my health services research training and experience through mentored research, formal coursework, and selfdirected learning activities and develop independence through leadership and networking opportunities. The current pace of U.S. healthcare spending is unsustainable as the oldest segments of the population expand. Hospital services account for the largest portion of Medicare costs, the bulk of which goes to a specific patient population: older adults with serious illness. Geographic regions vary widely in their intensity of hospital use and some argue this represents discretionary or unnecessary hospital-based care. Increased spending is also not associated with higher quality, as measured by longevity, quality of life, and satisfaction. Understanding what factors contribute to unnecessary hospitalizations among at-risk older adults is essential for development of successful new models of efficient, patient-centered care. Thus, the goal of my research is to prospectively identify seriously ill older adults at risk of hih-cost hospital-based care, and identify "triggers" of potentially avoidable hospitalizations and barriers to remaining in the community for these patients. Specifically, I plan to: (SA1) Build upon my prior work by examining determinants of hospital expenditures, number of hospital admissions and high-intensity, hospital-based treatment in the last year of life among the Health and Retirement Study (HRS) cohort using a mortality follow-back design; (SA2) Expand my earlier findings by evaluating factors associated with hospital expenditures, number of hospitalizations and treatment intensity among a cohort of seriously ill older adults matched prospectively by 1-year mortality risk; and (SA3) Support the development of an intervention to reduce unnecessary hospital admissions among at-risk older adults by investigating reasons for multiple hospital admissions and barriers to management outside the hospital among seriously ill older adults by conducting qualitative interviews with patients, caregivers and primary care physicians. The proposed work uses an innovative combination of regional, patient-level and claims data to evaluate factors driving treatment intensity in this population; examines outcomes with both a traditional mortality follow-back study design and a novel prospective analytic technique; and employs mixed methods to learn from patients and families what problems lead to excess hospitalizations and how those challenges might be overcome. Through my current work and future independent research, I plan to create a patient-centered intervention to reduce unnecessary hospitalizations among seriously ill older adults and translate my work to effective health care policies and clinical programs. The proposed research and career development plan are important initial steps toward advancing the care of older adults by improving medical decision making in the face of serious illness and promoting policies that better align treatments with patient preferences.