Goals of Care Discussions in Older Adults with Heart Failure and Their Caregivers

 描述（由申请人提供）：我的职业目标是成为一名独立的调查员，其工作改善了临床医生和晚期心力衰竭（HF）老年患者及其护理人员之间的对话。本申请提出了一个五年的课程和研究计划，旨在促进我的发展，以病人为导向的老龄化研究的独立调查员。在五年的奖项，我将扩大我的研究培训和经验，通过指导研究，正式的课程和自我导向的学习活动，并通过领导和网络机会发展独立性。本申请中提出的工作涉及研究晚期HF老年人的护理讨论目标（GOCD）。作为死亡、住院、再入院和医疗保险费用的主要原因之一，HF与患者健康相关的生活质量差、严重的心理困扰和医疗保健支出增加相关 和他们的照顾者。与其他严重疾病相比，晚期HF的复杂和不断变化的轨迹沿着可用的生命维持疗法使得老年人的决策更加复杂。晚期癌症患者的最新数据表明，GOCD可改善患者和护理人员的结局。与癌症不同，HF患者具有高度可变的疾病，与主要生活方式改变相关的侵入性潜在治疗，以及不可预测的症状危机，这使得难以将癌症的发现外推到HF。本提案旨在弥补这一差距。我们假设，与未患有GOCD的患者相比，改善的GOCD将改善患者结局（接受与偏好一致的治疗，更好的生活质量，更少的抑郁和焦虑以及利用率降低）和护理人员结局（更少的抑郁，焦虑和护理人员负担，以及改善的满意度）。这些项目的目的是：（SA 1）确定患有晚期HF的老年人GOCD的障碍和促进因素，并确定与GOCD相关的患者和护理人员健康相关的结果;（SA 2）开发和完善HF Connect，一种HF专用GOCD培训模块，以满足这些患者和护理人员的独特需求;和（SA 3）进行一项试验性随机对照试验（RCT），以确定入组的可行性、增加GOCD和高级护理计划行为的有效性以及对定制模块的满意度。为了实现第一个目标，我将分析一个多中心队列的晚期HF患者和他们的照顾者，以确定预测GOCD的因素和这些对话的结果。接下来，我将采访病人/照顾者二人组，以确定GOCD的障碍和促进因素。使用SA 1数据，我将开发HF Connect，并使用与患者、护理人员和临床医生的认知访谈来完善它（SA 2）。最后，我将对HF Connect（SA 3）进行一项小型RCT，以确定其可行性和有效性。这些研究将生成数据，使我能够获得R 01级资金，以在多中心RCT中测试HF Connect。拟议的研究和职业发展计划是改善晚期HF老年人及其护理人员护理的初步步骤。

 DESCRIPTION (provided by applicant): My career goal is to become an independent investigator whose work improves conversations between clinicians and older patients with advanced heart failure (HF) and their caregivers. This application proposes 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 my research training and experience through mentored research, formal coursework and self-directed learning activities and develop independence through leadership and networking opportunities. The work proposed in this application involves studying goals of care discussions (GOCD) in older adults with advanced HF. As one of the leading causes of death, hospitalization, readmission and Medicare costs, HF is associated with poor health-related quality of life, significant psychological distress and increased health care spending for patients and their caregivers. The complex and changing trajectory of advanced HF along with the available life-sustaining therapies makes decision-making more complex in older adults as compared to other serious illnesses. Recent data in advanced cancer patients demonstrate that GOCD result in improved patient and caregiver outcomes. Unlike cancer, HF patients have highly variable prognoses, invasive potential treatments associated with major lifestyle changes, and unpredictable symptom crises, which make it difficult to extrapolate findings from cancer to HF. This proposal aims to address this gap. We hypothesize that improved GOCD will result in improved patient outcomes (receipt of treatments aligned with preferences, better quality of life, less depression and anxiety and decreased utilization) and caregiver outcomes (less depression, anxiety and caregiver burden, and improved satisfaction) as compared to patients who do not have GOCD. The aims of these projects are: (SA1) to identify barriers and facilitators to GOCD in older adults with advanced HF and to identify patient and caregiver health-related outcomes associated with GOCD; (SA2) to develop and refine HF Connect, a HF- specific GOCD training module, to meet the unique needs of these patients and caregivers; and (SA3) to conduct a pilot RCT of PREPARE + HF Connect to determine feasibility of enrollment, efficacy to increase GOCD and advanced care planning behaviors, and satisfaction with the tailored module. To achieve the first aim, I will analyze a multicenter cohort of advanced HF patients and their caregivers to identify the factors that predict GOCD and outcomes of these conversations. Next, I will interview patient/caregiver dyads to identify barriers and facilitatorsof GOCDs. Using SA1 data, I will develop HF Connect and use cognitive interviews with patients, caregivers and clinicians to refine it (SA 2). Finally, I will conduct a small RCT of HF Connect (SA3) to determine its feasibility and efficacy. These studies will generate data that will allow m to secure R01-level funding to test HF Connect in a multicenter RCT. The proposed research and career development plan are initial steps toward improving the care of older adults with advanced HF and their caregivers.