Health Disparities in Timely Goals of Care Discussions and Hospitalizations Due to Infections in Nursing Home Residents

超过130万居民生活在全国1.56万家养老院(NHS)中。约90%的NH 居民年龄在65岁或以上，超过50%的人处于生命的最后阶段，强调 NHS作为重要的临终关怀机构。此外，NH居民极易感染H1N1流感 每年约有270万人感染，超过38万居民死于感染。 事实上，大约50%的NH居民因疑似感染而被转移到急救医院，以及 在这些住院治疗中，高达55%的患者被确定为潜在可以避免的。此外，黑人和西班牙裔 由于以下原因，居民更有可能接受次优姑息治疗，并有更高的住院率 与非西班牙裔和白人居民相比，感染人数有所增加。因此，建议及时 护理目标(TGOC)的讨论很早就开始了，并在整个护理轨迹中定期进行评估 临床医生在生命末期提供与目标一致的护理。在感染管理和研究中 临终关怀(SIMP-EL；R01 NR013687；Stone Pi和赞助商)研究人员确定Wide 关于何时引起居民和/或家庭对护理的偏好，NHS各有不同。然而，没有 其中一个研究了TGOC在NHS中的讨论如何因种族和民族以及其他社会决定因素而变化 健康包括居民、设施和社区层面的特点。此外，TGOC与TGOC的关系 讨论和因感染而住院的情况尚不清楚。拟议的研究将解决这些差距 通过使用多个数据源对横断面数据集进行二次分析，包括：1)SIMP- TGOC讨论的EL调查；2)NH居民评估的最低数据集3.0；3)联邦医疗保险 医院索赔数据的提供者和分析审查；以及4)其他公共可用的数据源(例如， 美国社区调查)了解设施和社区特征。由一个完整的概念指导 使用唐纳贝迪安人和少数人获得临终关怀模式的框架，具体目标是：(1) 根据居民、设施和社区特征确定NHS中TGOC讨论的差异，以及 (2)确定TGOC讨论与因感染住院之间的关联并进行检查 居民、设施和社区特征的差异。建议的目标与 国家护理研究所的研究重点是临终关怀和健康差距。为了方便 通过本次研究，申请者将增进对姑息治疗相关研究的认识和理解 长期护理环境中的感染结果、与临终护理过程有关的健康差距，以及 定量研究方法。凭借哥伦比亚大学专心致志的指导和资源丰富的环境 在大学期间，申请者将建立一个坚实的基础，以实现她的长期目标 成为一名独立的护士科学家，开发研究证据，为卫生政策和 确保为所有人提供及时、可获得和公平的临终关怀的指导方针。

Over 1.3 million residents live in the 15,600 nursing homes (NHs) across the nation. About 90% of NH residents are 65 years of age or older and more than 50% are in their final stage of life, emphasizing the role of NHs as important end-of-life care settings. In addition, NH residents are highly susceptible to infections with approximately 2.7 million infections occurring every year and more than 380,000 residents dying of infections. Indeed, about 50% of NH residents were transferred to acute care hospitals due to suspected infections, and up to 55% of these hospitalizations were identified as potentially avoidable. Furthermore, Black and Hispanic residents are more likely to receive suboptimal palliative care and have higher rates of hospitalizations due to infections compared to non-Hispanic and White residents. Therefore, it has been recommended that Timely Goals of Care (TGOC) discussions occur early and be evaluated periodically throughout the care trajectory for clinicians to provide goal-concordant care at the end-of-life. In the Study of Infection Management and Palliative Care at End-of-Life (SIMP-EL; R01 NR013687; Stone PI and sponsor) researchers identified wide variations across NHs regarding when residents and/or family preferences for care were elicited. However, no one has examined how TGOC discussions vary in NHs by race and ethnicity, and other social determinants of health including resident, facility, and community level characteristics. Also, the relationships between TGOC discussions and hospitalizations due to infections are not known. The proposed study will address these gaps through a secondary analysis of cross-sectional datasets using multiple data sources including: 1) the SIMP- EL survey for TGOC discussions; 2) the Minimum Data Set 3.0 for NH resident assessments; 3) the Medicare Provider and Analysis Review for hospital claims data; and 4) other publicly available data sources (e.g., American Community Survey) for facility and community characteristics. Guided by an integrated conceptual framework using the Donabedian and Minority Access to End-of-Life Care Models, the specific aims are to: (1) identify differences in the TGOC discussions in NHs by resident, facility, and community characteristics, and (2) determine the association between TGOC discussions and hospitalizations due to infections and examine differences by resident, facility, and community characteristics. The proposed aims are aligned with the National Institute of Nursing Research's research focus on end-of-life care and health disparities. To facilitate this research, the applicant will advance her knowledge and understanding on palliative care research related to infection outcomes in long-term care settings, health disparities related to end-of-life care processes, and quantitative research methods. With the dedicated mentorship and the resource-rich environment of Columbia University, the applicant will build a strong foundation from which to move toward her long-term goal of becoming an independent nurse scientist who develops research evidence that informs health policies and guidelines to ensure timely, accessible, and equitable end-of-life care for all.