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

心力衰竭患者的临终偏好和医疗资源使用

• 批准号: 9122441
• 负责人: Shannon Marie Dunlay
• 金额: $ 17.09万
• 依托单位: MAYO CLINIC ROCHESTER
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-08-20 至 2018-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9122441
• 关键词: Accounting; Acute; Address; Advance Care Planning; Advisory Committees; Advocate; Affect; Area; Award; Cardiovascular system; Caring; Cessation of life; Characteristics; Chronic; Chronic Disease; Client satisfaction; Clinic; Clinical Investigator; Clinical Research; Collaborations; Communication; Communities; Comprehensive Health Care; Consultations; County; Data; Data Analyses; Databases; Dedications; Development; Disease; EFRAC; Economic Burden; Emergency department visit; Enrollment; Ensure; Environment; Epidemiology; Event; Expenditure; Exposure to; Fostering; Foundations; Frequencies; Funding; Future; Gills; Goals; Guidelines; Health Care Reform; Health Services; Health Services Research; Healthcare; Healthcare Systems; Heart failure; Hospitalization; Individual; Influentials; Information Resources; Knowledge; Lead; Left Ventricular Function; Life; Measures; Medical; Medicare; Medicine; Mentored Patient-Oriented Research Career Development Award; Mentors; Mission; Modeling; Morbidity - disease rate; National Heart, Lung, and Blood Institute; Outcome; Outcome Measure; Outcomes and Health Services Research; Outpatients; Palliative Care; Palliative Medicine; Paper; Patient Care; Patient Preferences; Patients; Performance; Phenotype; Physicians; Positioning Attribute; Process; Provider; Public Health; Publishing; Quality of life; Questionnaires; Recommendation; Recruitment Activity; Research; Research Design; Research Infrastructure; Research Personnel; Resources; Resuscitation; Risk; Science; Services; Staging; Surveys; Syndrome; Techniques; Training; Work; base; career; cohort; cost; end of life; experience; frailty; health care delivery; health care disparity; health care service utilization; hospice environment; improved; meetings; mortality; outcome forecast; patient oriented; patient oriented research; population based; preference; shared decision making; skills; symposium; tool; working group

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.

描述（由申请人提供）：Dunlay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HF领域的独立健康服务和结果研究人员。她的短期目标是加强她的研究专业知识，并增加新的技能，成为精通必要的工具来执行这种类型的研究。她在K23期间的培训计划的关键组成部分包括： * 通过执行以下操作来增加她现有的技能： O 通过课程提高卫生服务研究知识 O 通过课程和实践掌握使用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 开发寿命终止和调查研究内容专业知识 * 通过在全国会议上展示她的工作，促进现有的和发展新的合作关系，申请参加早期职业委员会，并与卫生服务和成果研究的内部和外部专家合作。 * 发布高影响力结果：Dunlay博士将发表5篇由拟议目标产生的高级作者论文，并成为至少8篇证明成功合作证据的额外论文的共同作者 * 获得RO 1级资助：Dunlay博士将在获奖的第3年和第5年提交RO 1提案 博士Dunlay高度致力于在K23奖项期间成功过渡到独立的临床研究者。获得这个奖项对她实现目标至关重要。 环境马约诊所长期致力于以患者为中心的医学和以患者为导向的研究。通过其全面的基础设施，马约诊所既致力于又有能力培训医生研究人员，他们将成为心血管研究的未来领导者。马约诊所已确定卫生服务和成果研究作为一个关键需求和机构的优先事项，证明了最近的发展中心的科学提供医疗保健，由博士指导。Dunlay博士组建了一个由知名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奖项期间将她发展成为一名独立的临床研究者。最后，这些研究将在罗切斯特流行病学项目（REP）的主持下进行，该项目为基于社区的卫生服务研究提供了一个独特的完善框架，如本文所建议的。总之，机构环境和指导团队将确保Dunlay博士成功过渡到卫生服务和成果研究的独立职业生涯。 研究背景：晚期HF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影响，是一个主要的公共卫生问题。然而，尚不清楚临终患者的偏好和提前护理计划如何导致晚期HF医疗资源使用的差异。我们将通过拟议的研究解决这些知识差距。具体目标：首先，我们将研究生命末期的医疗保健利用以及HF类型（HFpEF，HFrEF），虚弱程度以及姑息治疗和临终关怀服务的使用（目标1）如何影响医疗保健利用。接下来，我们将调查提前护理计划的频率，包括患者与提供者关于生命结束的对话（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（包括住院治疗）的差异（目标3）。研究设计和结局指标：这些研究将在REP的主持下在明尼苏达州奥姆斯特德县进行。首先，在2003-2012年前瞻性入组本提案导师研究的HF患者人群队列中，我们将检查医疗资源利用情况死亡者在生命的最后6个月（住院、门诊和急诊）。使用Andersen-Gill模型解释重复事件，将按HF类型（HFpEF vs. HFrEF）和虚弱程度检查生命终了时的住院风险，调整潜在混杂因素。接受姑息医学咨询和临终关怀服务的人之间的医疗保健使用的差异也将进行检查。第二，我们将前瞻性招募连续奥姆斯特德县居民住院HF和评估他们的生命结束的偏好和参与提前护理计划使用面对面的问卷调查，并比较不同类型的HF和虚弱。最后，将对入组患者进行随访，并使用Andersen-Gill模型确定临终偏好与医疗资源使用之间的关联。潜在的公共卫生贡献：缺乏关于晚期HF的临终偏好及其与资源利用的相关性的数据。提出的目标将解决这些关键的知识差距，从而告知我们HF患者护理中的潜在差异，这些差异可能会干扰共同决策过程，如果得到改善，可能会减少住院率并提高患者满意度。与NHLBI使命的关系：这些研究旨在确定正确评估和治疗HF患者的方法，使他们能够过上更充实的生活，与NHLBI使命声明保持一致。与候选人职业目标的关系：拟议的研究将提供必要的高级接触，以HF人群为基础的卫生服务研究的性能，并将成为候选人建立HF卫生服务和结局研究职业生涯的基础。