Value of End-of-Life Cancer Care

临终癌症护理的价值

• 批准号: 9889081
• 负责人: Risha Gidwani Marszowski
• 金额: --
• 依托单位: VETERANS ADMIN PALO ALTO HEALTH CARE SYS
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-03-01 至 2019-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9889081
• 关键词: Achievement; Admission activity; Advanced Malignant Neoplasm; Age; Agreement; American Society of Clinical Oncology; Cancer Patient; Caring; Characteristics; Communities; Community Services; Consensus; Cost Effectiveness Analysis; Data; Development; Emergency department visit; Enteral Feeding; Failure; Family; Frequencies; Goals; Grant; Health Benefit; Health Expenditures; Healthcare; Healthcare Systems; Homelessness; Hospitals; Institute of Medicine (U.S.); Intensive Care; Intensive Care Units; Length of Stay; Life; Literature; Malignant Neoplasms; Marital Status; Measures; Mechanical ventilation; Medical; Medicare; Methods; Oncology; Outcome; Pain management; Palliative Care; Patient-Centered Care; Patient-Focused Outcomes; Patients; Perception; Persons; Policy Maker; Process; Quality of Care; Quality of life; Race; Resources; Resuscitation; Rural; Services; Supportive care; Surveys; System; Unmarried; Veterans; base; cancer care; care costs; care outcomes; chemotherapy; cost; disparity reduction; end of life; end of life care; experience; health care disparity; hospice environment; improved; instrument; overtreatment; pain outcome; pain score; patient oriented; preference; rurality; sex; sociodemographic group; sociodemographic variables; sociodemographics; symptom management; wasting

 DESCRIPTION (provided by applicant): Project Impact: This project evaluates the value of specific types of medical care provided in the last four weeks of life to Veterans dying of cancer, using a patient-centered perspective. The VA's top goals, as stated in the Blueprint for Excellence, are to deliver personalized, proactive, and patient-driven healthcare and to deliver high-value care. However, it is not currently clear at the end of life, what particular types of services are undesirable and low-value from a patient/family perspective, and importantly, whether desires for end-of-life care differ across socio-demographic groups (e.g., based on rural status, homelessness, marital status). In the last four weeks of life, it is important that patients receive high-quality, preference-concordant care that prioritizes symptom management and quality-of-life enhancing treatments over intensive medical services. This project will provide actionable information to VA managers to improve the end-of-life care experience for the more than 21,000 Veterans who die each year with advanced cancer, while also improving the value of care. For example, our results may indicate chemotherapy in the last 14 days of life is high cost, has a small positive impact on patient-centered outcomes, and occurs at low frequency. They may also indicate, for example, that ICU stay in the last month of life is high cost, has a large negative effect on patient-centerd outcomes, and occurs with high frequency. These results would indicate that to improve the value and the patient experience of end-of-life care, VA should prioritize reducing unnecessary ICU admissions over reducing unnecessary chemotherapy. Background: The American Society of Clinical Oncology (ASCO) and the National Quality Forum (NQF) have categorized certain services as unduly intensive at the end of life. These are: chemotherapy in the last 14 days of life; intensive care unit (ICU) admission in the last 30 days of life; more than 1 Emergency Department (ED) visit in the last 30 days of life; not admitted to hospice; and admitted to hospice for less than 3 days. There is strong agreement in the oncology and quality-of-care communities these services are inappropriate and avoidable, and represent a failure to provide appropriate palliative and supportive care to patients. Objective: While the medical community has come to strong consensus as to what constitutes unduly intensive care at the end-of-life, we evaluate whether patients and families have the same perceptions of these services. Specifically, we evaluate the value of these intensive end-of-life services, using a patient-centered perspective. We also evaluate any disparities that may exist in the receipt of these services by Veteran priority status, race, sex, age, marital status, homelessness, or rural status. Methods: In healthcare, value indicates an achievement of outcomes proportional to the resources spent to achieve them. We therefore examine the value of specific end-of-life services through analyses of administrative data regarding processes of and cost of care at the end of life combined with patient-centered outcomes obtained from the Bereaved Family Survey. Our study will produce a value quadrant, similar to that seen in cost-effectiveness analyses. This value quadrant will indicate which intensive services have: a) a large impact on costs and a large impact on outcomes; b) a large impact on costs and a small impact on outcomes; c) a small impact on costs and a small impact on outcomes; and d) a small impact on costs and a large impact on outcomes. Our results will also indicate the frequency with which each intensive service occurs in VA. This information regarding the value of end-of-life care represents an entirely new contribution to the literature.

 描述（由申请人提供）： 项目影响：该项目评估了在生命的最后四周内为死于癌症的退伍军人提供的特定类型的医疗护理的价值，使用以患者为中心的观点。正如卓越蓝图中所述，VA的首要目标是提供个性化，主动和患者驱动的医疗保健，并提供高价值的护理。不过，目前尚不清楚在 生命的结束、从患者/家庭的角度来看哪些特定类型的服务是不期望的和低价值的，以及重要的是，对生命结束护理的期望是否在社会人口统计学群体中不同（例如，根据农村状况、无家可归、婚姻状况）。在生命的最后四周，重要的是患者接受高质量，偏好一致的护理，将症状管理和提高生活质量的治疗优先于强化医疗服务。该项目将为退伍军人管理人员提供可操作的信息，以改善每年死于晚期癌症的21，000多名退伍军人的临终护理体验，同时提高护理的价值。例如，我们的研究结果可能表明，在生命的最后14天内进行化疗的成本很高，对以患者为中心的结局的积极影响很小，并且发生频率很低。例如，他们还可能表明，生命最后一个月的ICU停留成本高，对以患者为中心的结局有很大的负面影响，并且发生频率高。这些结果表明，为了提高临终关怀的价值和患者体验，VA应该优先减少不必要的ICU入院，而不是减少不必要的化疗。背景资料：美国临床肿瘤学会（ASCO）和国家质量论坛（NQF）将某些服务归类为生命末期过度密集的服务。这些是：在生命的最后14天内接受化疗;在生命的最后30天内入住重症监护室（ICU）;在生命的最后30天内急诊科（艾德）就诊超过1次;未入住临终关怀医院;入住临终关怀医院少于3天。在肿瘤学和护理质量社区中有强烈的一致意见，这些服务是不适当的和可以避免的，并且代表未能向患者提供适当的姑息和支持性护理。目的：虽然医学界已经达成了强烈的共识，什么是不适当的重症监护在生命的最后，我们评估患者和家属是否有这些服务相同的看法。具体来说，我们评估这些密集的生命终了服务的价值，使用以病人为中心的角度。我们还评估了退伍军人优先地位，种族，性别，年龄，婚姻状况，无家可归者或农村状况在接受这些服务时可能存在的任何差异。 方法：在医疗保健中，价值是指与实现这些目标所花费的资源成比例的成果。因此，我们研究的价值，具体的临终服务，通过分析行政数据的过程和成本的护理在生命的尽头结合以病人为中心的结果从丧亲家庭调查。我们的研究将产生一个价值象限，类似于在成本效益分析中看到的。这一价值象限将表明哪些密集型服务具有：a）对成本影响大，对成果影响大; B）对成本影响大，对成果影响小; c）对成本影响小，对成果影响小; d）对成本影响小，对成果影响大。我们的研究结果还将表明频率与每一个密集的服务发生在VA。关于临终关怀价值的这一信息是对文献的一个全新贡献。