Improving The Quality Of Advanced Cancer Care With Disease Management

描述（由申请人提供）：晚期癌症患者需要获得以治愈为导向的治疗和姑息治疗。国家综合癌症网络（NCCN）将姑息治疗的目标确定为预防和减轻痛苦，无论疾病的阶段如何，也无论姑息治疗是与延长生命的护理同时提供还是作为护理的主要重点。尽管认识到症状管理专业知识的重要性和关注癌症经历的心理社会方面，患者继续发现姑息治疗和临终关怀的缺点，包括缺乏协调和沟通，难以获得护理，症状管理不足，延长死亡过程。要取得重大改进，就必须改变提供保健的制度，以确保：（a）病人能够得到专家对身体、心理和精神需求的管理以及良好的治疗（B）病人家属得到同样的专家支助;（c）第（1）款获得专业人员谁的技能和时间，以帮助病人及其家属作出过渡，从一个主要目标的治愈，姑息治疗的目标是现成的;和（d）协调过渡到社区提供者，如家庭护理，姑息治疗计划，临终关怀发生。越来越多的证据表明，疾病管理是一种能够专门解决这些需求的护理模式，尽管它从未在学术癌症中心进行过测试。本研究的目的是实施一个全面的疾病管理计划（CDC），并衡量对晚期癌症患者及其家属的生活质量和护理质量的影响，并检查对资源使用的影响。将采用两组、准实验、串联入组设计。研究问题是：（1）与接受常规治疗的晚期癌症患者相比，参加过化疗的晚期癌症患者在资源使用（生命最后30天内的化疗治疗次数、急诊室就诊次数、临终关怀和住院天数）方面是否存在差异？(2)与接受常规护理的患者相比，参加过康复治疗的晚期癌症患者的患者结局（健康相关的生活质量、精神健康、对护理的满意度）是否存在差异？(3)与接受常规护理的患者相比，参加过康复治疗的晚期癌症患者的护理者在护理结果（情绪状态、护理满意度、临终护理满意度和康复负担）方面是否存在差异？(4)在控制了人口统计学、临床和组织协变量的影响后，患者和护理者的结局差异是否仍然存在？(5)通过改善协作和解决问题，患者和护理人员的结果有多大程度的差异？

DESCRIPTION (provided by applicant): Patients with advanced stage cancer have need for access to both cure-oriented therapies and palliation. The National Comprehensive Cancer Network (NCCN) identifies the goal of palliative care as the prevention and relief of suffering regardless of the stage of disease and regardless of whether palliative care is provided concurrently with life-prolonging care or as the main focus of care. Despite recognition of the importance of symptom management expertise and attention to the psychosocial aspects of the cancer experience, patients continue to identify shortcomings in palliative care and end-of-life care, including lack of coordination and communication, difficulty accessing care, inadequate symptom management, and prolongation of the dying process. Significant improvements require changes in the care delivery system in order to assure that: (a) patients have access to expert management of physical, psychological, and spiritual needs as well as excellent curative therapy (b) families of patients receive the same expert support; (c) access to professionals who have the skills and time to assist patients and their families make the transition from a primary goal of cure to a primary goal of palliation is readily available; and (d) a coordinated transition to community providers, such as home care, palliative care programs, and hospice occurs. There is growing evidence that disease management is a care delivery model that is able to specifically address these needs, although it has never been tested in an academic cancer center. The purpose of this investigation is to implement a comprehensive disease management program (DMP) and measure effects on quality of life and quality of care of advanced cancer patients and their families, and to examine the effects on resource use. A two-group, quasi-experimental, tandem enrollment design will be used. Research questions are: (1) Is there a difference in resource use (number of chemotherapy treatments in the last 30 days of life, number of emergency room visits, number of days of hospice and hospitalization) among patients with advanced cancer who have participated in a DMP compared to those receiving usual care? (2) Is there a difference in patient outcomes (health related quality of life, spiritual well being, satisfaction with care) among patients with advanced cancer who have participated in a DMP compared to those receiving usual care? (3) Is there a difference in caregiver outcomes (mood state, satisfaction with care, satisfaction with end of life care, and burden of caregiving) among caregivers of patients with advanced cancer who have participated in a DMP compared to those receiving usual care? (4) Do the differences in patient and caregiver outcomes remain after controlling for the influence of demographic, clinical and organizational covariates? (5) To what extent are differences in patient and caregiver outcomes achieved through improvements in collaboration and problem solving?