Provider and Organizational Norms and Care at End of Life (PONCEL): A Study of Tw

描述(由申请人提供)：医院在住院频率和住院时间、重症监护病房(ICU)入院时间以及为患有慢性病的联邦医疗保险受益人在生命的最后6个月期间咨询的专家数量方面存在显著差异。我们建议的目标是通过深入的医院案例研究来探索这一现象。目标是确定在高强度医院中可以改变的提供者和组织规范，以提高治疗效率和以患者为中心。本R21的具体目标是：1.确定和描述影响在一家低强度和一家高强度美国医院的ICU中为慢性/危重患者使用LST的组织和提供者实践规范。2.探索这些组织和提供者实践规范与提供者士气、家庭满意度、质量和护理结果的相关性。研究设计要求面试者和现场工作人员对ICU病例进行为期4周的影子观察和深入分析，基于对提供者、管理人员、非临床工作人员和患者或代理决策者的半结构化访谈。我们将在扎根理论的指导下，混合使用实地笔记和访谈记录的定性内容分析，以及对医院利用和结果数据以及提供者、患者和家庭调查数据的定量分析，以开发假设并得出关于规范、强度和结果之间的关系的结论。一个由专家组成的咨询委员会将与调查人员和医院工作人员合作，为社会营销干预制定想法，未来可能会进行测试，以改变高强度医院的规范。拟议项目与公共卫生的相关性源于更好地了解提供者和组织规范可能如何支持或干扰危重老年人对决策和结果的偏好。我们将如何衡量该项目的成功的一个例子是，确定一种社会规范，鼓励在低强度医院出院时预先制定护理计划，并利用社会营销将其输出到高强度医院，以实现减少患有严重慢性病的老年人的数量，限制与生命维持有关的慢性病，并在ICU死亡。

DESCRIPTION (provided by applicant): Hospitals vary markedly in the frequency and length of hospitalizations and intensive care unit (ICU) admissions and the number of specialists consulted for chronically ill Medicare beneficiaries during their last 6 months of life. The objective of our proposal is to explore this phenomenon using in-depth hospital case studies. The goal is to identify provider and organizational norms that can be changed in high intensity hospitals to improve efficiency and patient-centeredness of treatment. The specific aims of this R21 are: 1. Identify and describe organizational and provider practice norms that influence the use of LSTs in the ICU for chronically/critically ill elders at one low and one high intensity US hospital. 2. Explore the correlation of these organizational and provider practice norms with provider morale, family satisfaction, quality, and outcomes of care. The research design involves an interviewer and fieldworker engaging in 4 weeks of shadow observation and in-depth analysis of ICU cases based upon semi-structured interviews with the providers, managers, non- clinical staff, and patients or proxy decision makers involved. We will use a mixture of qualitative content analysis of field-notes and interview transcripts, guided by grounded theory, and quantitative analysis of hospital utilization and outcomes data and of provider, patient, and family survey data to develop hypotheses and to draw conclusions about the relationships between norms, intensity, and outcomes. An advisory committee of experts will collaborate with the investigators and hospital staff to develop ideas for a social marketing intervention that could be tested in the future to change norms at the high intensity hospital. The relevance of the proposed project to public health derives from a better understanding of how provider and organizational norms may support or interfere with preferences for decision making and outcomes among critically ill elders. An example of how we would measure success of the project would be the identification of a social norm that encourages advance care planning upon hospital discharge at the low intensity hospital that could be exported using social marketing to the high intensity hospital in order to achieve a reduction in the number of elders with severe limiting chronic illnesses connected to life-support and dying in the ICU.