Impact of POLST Adoption and of Financial Incentives on Care Receipt and on Intensity of Care Preferences in Nursing Home Patients

摘要 高级护理计划(ACP)，包括临终关怀(EOL)讨论和决策，非常重要 护理慢性病和危重病人的要素。理想情况下，医生会与 根据患者的目标和价值观，对患有无法治愈的、限制生命的疾病的患者进行治疗选择。 这些对话涵盖了如何积极治疗疾病以及最终选择临终关怀的问题。 理想情况下，这些对话应该在病人去世或病情严重到无法进行这些对话之前很久就进行。 讨论。然而，在许多情况下，患者和提供者之间不会发生ACP讨论。 针对机场核心计划的这一需要，包括对停产问题的讨论和决策，一些重要的变化 已经发生了。在全国范围内，标准化患者喜好表格的框架-医生生命命令 持续治疗(POLST)或其等价物-已被开发并在各州推出 基础。加利福尼亚州在2009年采用了POLST，并开始例行收集POLST作为补充(S部分) 到疗养院居民的长期护理最低数据集(MDS)。在全国范围内，CMS始于 2016年1月向提供商报销进行ACP讨论，鼓励提供商发起、 重新访问并报告这些讨论。 这两项单独的政策干预措施的结合--逐个州实施POLST和 针对ACP讨论的Medicare报销-允许对患者的偏好和他们的 (当鼓励/促进收集时)对护理选择和结果的影响。使用国家养老院 数据(MDS)，加州MDS部门S，联邦医疗保险登记数据和FFS索赔，以及加州所有支付者 医院数据(2011年至2018年)，我们提出了以下目标和相关假设 对医疗保险中与ACP讨论相关的标准化和财政激励的影响进行评估 年龄在65岁及以上的参赛者： 1.评估POLST的推出对EOL的护理利用率和EOL的护理质量的影响 全国疗养院的FFS医疗保险患者。 2.评估针对ACP讨论的Medicare FFS支付政策对EOL医疗服务利用率的影响 以及全国疗养院FFS Medicare患者在EOL的护理质量。 3.评估针对ACP讨论的医疗保险支付政策对POLST完成情况的影响，患者 加州养老院中途停产护理的偏好、利用和质量 居民参加了医疗保险。 这项研究将评估政策对全国老年人护理的影响，并将例行公事地利用独特 从加州收集POLST数据，以量化医生激励对患者的直接影响 偏好。研究结果将成为机场核心计划讨论和停工计划进一步创新的催化剂。

ABSTRACT Advance care planning (ACP), including end-of-life (EOL) discussions and decision-making, are important elements for the care of chronically and critically ill patients. Ideally, doctors would have conversations with patients with incurable, life-limiting illnesses about treatment options, based on the patient’s goals and values. These conversations cover how aggressively to treat an illness as well as the option eventually for hospice. These conversations ideally should happen long before a patient dies or becomes too ill to have these discussions. However, in many cases, ACP discussions between patients and providers do not occur. In response to this need for ACP, including EOL discussions and decision-making, some important changes have occurred. Nationally, a framework for standardizing patient preference forms – Physician Orders for Life Sustaining Treatment (POLST) or their equivalent – have been developed and introduced on a state-by-state basis. California adopted POLST in 2009 and began routinely collecting POLST as a supplement (Section S) to the Long-Term Care Minimum Data Set (MDS) for nursing home residents. Nationally, CMS began in January 2016 to reimburse providers to have ACP discussions, creating an incentive for providers to initiate, revisit, and report these discussions. The combination of these two separate policy interventions – state-by-state implementation of POLST and Medicare reimbursement for ACP discussions – allow for empiric evaluation of patient preferences and their impact (when collection is encouraged/facilitated) on care choices and outcomes. Using national nursing home data (MDS), California MDS Section S, Medicare enrollment data and FFS claims, and California all-payer hospital data (years 2011 to 2018), we propose the following aims and associated hypotheses for the evaluation of the impact of standardization and financial incentives related to ACP discussions in Medicare enrollees 65 years of age and older: 1. Assess the impact of POLST rollout on utilization of care at EOL and quality of care at the EOL among FFS Medicare patients in nursing homes nationally. 2. Assess the impact of Medicare FFS payment policy for ACP discussions on utilization of care at EOL and quality of care at the EOL among FFS Medicare patients in nursing homes nationally. 3. Assess the impact of Medicare payment policy for ACP discussions on POLST completion, patient preferences, and utilization of care at EOL and quality of care at the EOL in California nursing home residents enrolled in Medicare. This study will evaluate the policy impact on care for the elderly nationally and will leverage unique routinely collected POLST data from California to quantify the direct impact of physician incentives on patient preferences. Study results will be a catalyst for further innovation in ACP discussions and EOL planning.