Isolating Mechanisms Underlying Hospital Variation in End-of-Life ICU Use

临终 ICU 使用中医院差异的隔离机制

• 批准号: 7707711
• 负责人: AMBER E BARNATO
• 金额: $ 21.9万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-06-01 至 2011-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7707711
• 关键词: Academic Medical Centers; Admission activity; Aftercare; Atlases; Automobile Driving; Behavior; Behavioral; Characteristics; Client satisfaction; Clinical; Code; Cognitive; Communication; Complement; Consensus; Critical Illness; Data; Decision Making; Diagnostic Neoplasm Staging; Documentation; Environment; Event; Failure; Family; Funding; Future; Goals; Healthcare; Hospitals; Institution; Intensive Care; Intensive Care Units; Intervention; Intervention Studies; Interview; Intubation; Investigation; Life; Link; Mediating; Medical; Methods; Observational Study; Patients; Pattern; Physicians; Policies; Procedures; Process; Provider; Recruitment Activity; Role; Shapes; Simulate; Social Marketing; Source; Techniques; Time; Training; Triage; United States National Institutes of Health; Universities; Variant; base; design; end of life; end-of-life decision making; improved; meetings; older patient; palliation; patient population; preference; pressure; psychosocial; public health relevance; research study; satisfaction; simulation; skills; social; tool

DESCRIPTION (provided by applicant): The Dartmouth Atlas of Health Care has demonstrated considerable variability among hospitals in intensive care unit (ICU) use at the end of life. Efforts to determine how much of this variability is due to differences in provider behavior are hindered by other factors that vary simultaneously across hospitals, such as patients' clinical condition, psychosocial circumstances, and preferences for treatment. We propose to augment our currently-funded NIH observational study of the medical intensive care units (MICUs) of a high-intensity academic medical center and a low-intensity academic medical center (R21 NR010265) with a simulation experiment at the same two institutions. While the observational study focuses on decisions that are made after patients have been admitted to the ICU, our simulation of a patient with end-stage cancer is designed to study the decision whether to admit a patient to the ICU in the first place, a decision event that is hard to study observationally, given the unpredictable timing of these events. In addition, by placing physicians in a simulated environment with an identical case, we can isolate the provider sources of variation among two hospitals at opposite ends of the end-of-life intensity spectrum. By exploring the rationales physicians offer to explain their behavior, we can further parse part of the causes of the variation into formal norms (hospital policies and procedures) and informal social norms. Of the many factors driving end-of-life decision making, informal social norms are one of the least understood. Social norms are also potentially modifiable with social marketing interventions. By complementing the data from our observational study with these experimental data, we will have a much clearer and broader picture of ICU use at the end of life, which we will use to inform a future intervention study to improve patient and family satisfaction with physician decision making. The specific aims are: Aim 1: To compare ICU admission, palliation, and code status documentation decisions among hospital- based physicians at one high-intensity and one low-intensity academic medical center using high-fidelity simulation. Aim 2: To examine the relationship between communication skills and ICU admission, palliation, and code status documentation decisions using simulation data from the 2 academic medical centers, augmented by previously collected data from a mid-intensity academic medical center. Aim 3: To identify formal and informal social norms that influence ICU admission, palliation, and code status documentation decisions at the high-intensity and the low-intensity academic medical centers. PUBLIC HEALTH RELEVANCE: The overall goal of this project is to enhance our understanding of the reasons for hospital-level variations in end-of-life (EOL) intensive care unit (ICU) use among patients with end-stage cancer. We will use a high- fidelity simulation, similar in sophistication to flight simulators used for pilots, to assess and compare the communication and decision-making processes of hospital-based physicians from an academic medical center with high EOL ICU use to those of physicians from an academic medical center with low EOL ICU use. By placing physicians in a simulated environment with an identical case, we can isolate the provider sources of variation among two hospitals at opposite ends of the end-of-life intensity spectrum. By exploring the rationales physicians offer to explain their behavior, we can further parse part of the causes of the variation into formal norms (hospital policies and procedures) and informal social norms. Our findings will be used to develop hospital-level interventions to improve the patient-centeredness of communication and decision making for dying patients. This study will also provide further support for the simulation method we have developed, which could be used in the future as a technique for identifying mechanisms underlying physician behavior and as a training tool for changing physician behavior.

描述（由申请人提供）：达特茅斯卫生保健地图集已经证明，在生命末期重症监护室（ICU）使用的医院之间存在相当大的差异。努力确定这种变化有多少是由于提供者行为的差异受到其他因素的阻碍，这些因素在医院之间同时变化，例如患者的临床状况，心理社会环境和治疗偏好。我们建议通过在相同的两个机构进行模拟实验来增强我们目前资助的NIH观察性研究，即高强度学术医疗中心和低强度学术医疗中心（R21 NR010265）的医疗重症监护室（MICU）。虽然观察性研究的重点是在患者进入ICU后做出的决定，但我们对终末期癌症患者的模拟旨在研究是否首先将患者送入ICU的决定，考虑到这些事件的不可预测时间，很难观察研究决策事件。此外，通过将医生放置在具有相同病例的模拟环境中，我们可以在寿命终了强度谱的相对两端隔离两家医院之间的变化的供应商来源。通过探讨医生提供的解释他们的行为的理由，我们可以进一步解析变异的部分原因为正式规范（医院的政策和程序）和非正式的社会规范。在推动临终决策的许多因素中，非正式的社会规范是最不被理解的因素之一。社会规范也有可能通过社会营销干预来改变。通过用这些实验数据补充我们观察性研究的数据，我们将对生命结束时ICU的使用有一个更清晰和更广泛的了解，我们将用它来为未来的干预研究提供信息，以提高患者和家庭对医生决策的满意度。具体目标是：目标1：使用高保真模拟比较一个高强度和一个低强度学术医学中心的医院医生的ICU入院、姑息治疗和代码状态记录决策。目标二：使用来自2个学术医疗中心的模拟数据，并通过先前从中等强度学术医疗中心收集的数据进行增强，检查沟通技能与ICU入院、缓解和代码状态文件决策之间的关系。目标三：确定正式和非正式的社会规范，影响ICU入院，姑息治疗和代码状态文件的决定，在高强度和低强度的学术医疗中心。公共卫生相关性：该项目的总体目标是提高我们对终末期癌症患者使用临终（EOL）重症监护室（ICU）的医院水平变化的原因的理解。我们将使用高保真度模拟，类似于用于飞行员的飞行模拟器，以评估和比较来自使用高EOL ICU的学术医疗中心的医院医生与来自使用低EOL ICU的学术医疗中心的医生的沟通和决策过程。通过将医生放置在具有相同病例的模拟环境中，我们可以在寿命终了强度谱的相对两端隔离两家医院之间的差异的提供者来源。通过探讨医生提供的解释他们的行为的理由，我们可以进一步解析变异的部分原因为正式规范（医院的政策和程序）和非正式的社会规范。我们的研究结果将用于制定医院级干预措施，以改善以患者为中心的沟通和决策垂死的病人。这项研究还将为我们开发的模拟方法提供进一步的支持，这种方法可以在未来用作识别医生行为机制的技术，并作为改变医生行为的培训工具。