Needs and Outcomes of Elders with Hip Fracture: Supportive, Functional, Palliativ

描述(申请人提供)：髋部骨折是老年人生活中的一种前哨急性事件。虽然没有被经典地作为临终状态进行研究，但它经常导致向功能依赖和死亡的过渡。目前髋部骨折研究和临床护理的范式是这样一种范式，即护理的主要目标是使患者恢复到骨折前的功能水平。这是一个非常有价值的目标，但它需要 平衡的理解是，大多数髋部骨折患者不能恢复到以前的功能水平。我们需要治疗范例，将髋部骨折后预后不佳的患者的支持性和姑息性治疗视为重要的护理目标。然而，为髋部骨折后的老年人提供支持性和姑息性服务的能力 由于几乎没有以人口为基础的数据，说明髋部骨折后最有可能功能恢复不佳的人有哪些需求，以及髋部骨折后确实健康状况不佳的患者目前接受的护理类型，这一点受到了阻碍。为了解决这一差距，我们将创建必要的信息数据库，以指导政策制定者和那些计划进行干预研究的人，这些研究将更好地满足髋部骨折患者的支持性和姑息性需求，这些患者无法恢复以前的功能水平。具体地说，我们将创建一个具有全国代表性的髋部骨折老年人数据库，以解决三个主要问题。首先，髋部骨折的负担如何影响对日常生活基本和工具性活动的个人帮助的需求？第二，髋部骨折后预后不良的预测因素是什么？第三，目前对髋部骨折后一年死亡的老年人的临终关怀模式是什么？我们建议机会主义地使用健康和退休研究(HRS)来更好地确定髋部骨折老年人的支持和姑息需求。HRS的几个引人注目的特征使其成为本研究的理想选择。首先，由于HRS的规模和大量的随访，HRS使研究大量髋部骨折的老年人成为可能，这些数据包括髋部骨折前后的健康、功能状况和护理需求。其次，HRS拥有关于医疗和心理社会风险领域的广泛数据，这将增强识别那些预后不良风险最高的人的能力。第三，由于HRS与医疗保险挂钩，我们可以详细描述临终前接受的护理类型。第四，因为它在死后采访近亲，我们将能够了解症状控制的质量和临终计划的要素。HRS使我们能够以具有成本效益的方式进行一项使用主要数据收集方法不可能进行的研究。我们建议进行一项具有以下目的的队列研究：目的1：描述髋部骨折前两年和髋部骨折后两年在日常生活的基本和工具性活动中对个人援助的需求。目的2：确定哪些老年人髋部骨折后死亡和残疾的风险最高。目的3：在髋部骨折后一年内死亡的患者中，描述资源使用模式(医院、ICU和临终关怀)、死亡地点、提前护理计划和症状控制质量。

DESCRIPTION (provided by applicant): Hip fracture is a sentinel acute event in the life of an older person. While not classically studied as an end-of- life condition, it frequently precipitate a transition to functional dependence and death. Current paradigms of hip fracture research and clinical care have been informed by a paradigm in which the primary goal of care is to return patients to their pre-fracture level of functioning. This is a very worthy goal, but it needs to be balanced by the understanding that the majority of persons with hip fracture do not return to their prior level of functioning. We need treatment paradigms that view supportive and palliative treatment of patients with poor outcomes following hip fracture as important goals of care. However, the ability to provide supportive and palliative services to elders following hip fracture is hampered because there is virtually no population-based data about what those needs are who is most likely to have poor functional recovery following hip fracture, and the types of care currently received by patients who do have poor health outcomes following hip fracture. To address this gap, we will create the information database that is needed to guide policy makers and those planning intervention studies that will better address the supportive and palliative needs of hip fracture patients who do not return to their prior level of functioning. Specifically,we will create a nationally representative database of older persons with hip fracture to address three primary questions. First, how does the burden of hip fracture affect the need for personal assistance with basic and instrumental activities of daily living? Second, what are the predictors of poor outcomes following hip fracture? Third, what is the current end-of- life care patterns for elders who die in the year after hip fracture? We propose opportunistic use of the Health and Retirement Study (HRS) to better define supportive and palliative needs of elders with hip fracture. Several compelling features of the HRS make it ideal for this study. First, because of it size and the considerable follow-up, the HRS makes it possible to study large numbers of elders with hip fracture with extensive data on their health, functional status, and care needs both before and after hip fracture. Second, the HRS has extensive data on medical and psychosocial domains of risk that will enhance the ability to identify those at highest risk of poor outcomes. Third, because the HRS is linked to Medicare, we can paint a detailed description of the type of care received towards the end of life. Fourth, because it interviews next of kin after death, we will be able to learn about the quality of symptom control and elements of end-of-life planning. The HRS allows us to conduct a study that would be impossible using primary data collection approaches in a cost-effective manner. We propose a cohort study with the following aims: Aim 1: Describe the need for personal assistance in basic and instrumental activities of daily living i the two years before and the two years after hip fracture. Aim 2: Determine which elders are at highest risk for death and disability following hip fracture. Aim 3: Among those who die in the year after hip fracture, describe patterns of resource use (hospital, ICU, and hospice), location of death, advance care planning, and quality of symptom control.