Beyond 30-Days: Patient-Oriented Outcomes Among Older Adults After Emergency General Surgery

项目概要/摘要 急诊普通外科（EGS）手术是老年人中最病态和最常见的手术之一。 成年人了老年EGS患者的术后死亡风险是择期手术后老年患者的3倍。 手术，比年轻EGS患者高2-7倍。此外，多达一半的老年EGS患者 经历术后并发症，大多数人出院到疗养院。随着人口结构的变化， 老年人的EGS率预计会增加。然而，与以下方面特别相关的成果： 老年EGS患者，如生存期超过30天，功能和认知轨迹，生活质量， 姑息治疗的需求是未知的。本提案利用多种数据填补了这些知识空白 来源和补充方法。首先，医疗保险索赔将用于检查12个月的生存率 和卫生保健利用率的数据。其次，将从队列中收集主要前瞻性数据 老年EGS患者及其代理人，以检查次要数据集中不可用的关键结局，包括 症状负担、功能和认知状态、生活质量、提前护理计划和终末质量 生活护理。第三，对患者和代理人的半结构化访谈进行定性分析， 对他们的生活经历有了更丰富的了解。具体目标是：1。利用国家 医疗保险索赔描述12个月的结果，包括生存，急性后疗养院的使用， 老年EGS患者（N= 650，157）的再住院和临终关怀使用，确定了与更好的治疗相关的因素。 结果，并在急诊住院患者的倾向匹配队列中比较这些结果 对于三种常见的医学状况（肺炎、充血性心力衰竭和心肌梗塞， N= 2，013，861）; 2.前瞻性随访老年EGS患者（n~150）及其代理人（n~150） 到术后12个月，以确定与更少的医院转移，更好的质量， 更好的生活，更好的生活; 3。用现象学的方法定性分析半 对目标2队列中的患者（N=20）和代理人（N=20）进行结构化访谈，以获得深入的 了解在以下领域改善术后护理的机会：提供者的质量 沟通，提前护理计划，症状管理，护理过渡和代理体验。 影响：这项工作代表了改善老年EGS患者手术护理的关键步骤， 个人临床决策，设定恢复预期，帮助计划后续的医疗保健需求， 并揭示目标，以改善这些患者的手术护理和姑息治疗。最后，工作 将使申请人成为为数不多的具有老龄化专业知识的外科健康服务研究人员之一， 姑息治疗，并将准备她成为一个独立的R 01资助的调查员。

Project Summary/Abstract Emergency General Surgery (EGS) procedures are among the most morbid and common operations in older adults. Postoperative mortality risk in older EGS patients is 3 times higher than for older patients after elective surgery, and 2-7 times higher than for younger EGS patients. Moreover, up to half of older EGS patients experience postoperative complications and most are discharged to nursing homes. With demographic shifts, the rate of EGS in older adults is expected to increase. However, outcomes that are particularly relevant to older EGS patients such as survival beyond 30-days, functional and cognitive trajectories, quality of life, and palliative care needs are unknown. This proposal addresses these knowledge gaps utilizing multiple data sources and complementary methodologies. First, Medicare Claims will be used to examine 12-month survival and health care utilization in a national cohort. Second, primary prospective data will be collected from a cohort of older EGS patients and their proxies to examine key outcomes unavailable in secondary datasets including symptom burden, functional and cognitive status, quality of life, advance care planning, and quality of end-of- life care. Third, qualitative analyses of semi-structured interviews with patients and proxies will be done to obtain a richer understanding about their lived experience. The Specific Aims are: 1. To use National Medicare Claims to describe 12-month outcomes including survival, post-acute nursing home use, rehospitalization, and hospice use in older EGS patients (N=650,157), identify factors associated with better outcomes, and to compare these outcomes in a propensity-matched cohort of patients emergently hospitalized for three common medical conditions (pneumonia, congestive heart failure, and myocardial infarction, N=2,013,861); 2. To prospectively follow a cohort of older EGS patients (n~150) and their proxies (n~150) up to 12 months after surgery, to identify modifiable factors associated with fewer hospital transfers, better quality of life, and better end-of-life care; and, 3. To use a phenomenological approach to qualitatively analyze semi- structured interviews with patients (N=20) and proxies (N=20) from the cohort in Aim 2, to obtain an in-depth understanding of opportunities to improve post-surgical care in the following domains: quality of provider communication, advance care planning, symptom management, care transitions, and proxy experience. IMPACT: This work represents key steps in improving surgical care for older EGS patients by directly informing individual clinical decisions, setting expectations for recovery, helping to plan subsequent heath care needs, and revealing targets to improve surgical care delivery and palliative care for these patients. Finally, the work will establish the applicant as one of the few surgical health services researchers with expertise in aging and palliative care, and will prepare her to become an independent R01-funded investigator.