Identifying barriers, facilitators and outcomes of Advanced Care Planning conversations with Medicare patients

确定与 Medicare 患者进行高级护理计划对话的障碍、促进因素和结果

• 批准号: 9763016
• 负责人: Joel S. Weissman
• 金额: $ 47.54万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-09-11 至 2021-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9763016
• 关键词: Address; Admission activity; Adoption; Advance Care Planning; American; Atlases; Bereavement; Caregivers; Caring; Case Study; Cessation of life; Chronic Obstructive Airway Disease; Clinical; Data; Dementia; Diagnostic; Effectiveness; Elderly; Environmental air flow; Expenditure; Face; Fee-for-Service Plans; Focus Groups; Frequencies; Geography; Health Expenditures; Health system; Heart failure; Hospice Care; Hospital Referrals; Hospitals; Improve Access; Incidence; Individual; Institute of Medicine (U.S.); Integrated Health Care Systems; Intensive Care; Intensive Care Units; Intervention; Interview; Kidney Failure; Life; Life Expectancy; Location; Lung diseases; Malignant Neoplasms; Medical; Medicare; Medicare claim; Mental Health; Methods; Neurodegenerative Disorders; Nurses; Nursing Specialties; Operative Surgical Procedures; Outcome; Palliative Care; Patient Care; Patients; Pattern; Physicians; Policies; Population; Prevalence; Prospective cohort; Qualitative Methods; Quality of Care; Recommendation; Research; Research Personnel; Resources; Resuscitation; Services; Structure; System; Technology; Terminally Ill; Time; Time trend; United States Centers for Medicare and Medicaid Services; Vacuum; care costs; care delivery; care outcomes; chemotherapy; clinical practice; contextual factors; end of life; end of life care; health organization; hospice environment; improved; medical specialties; older patient; palliative; preference; research study; surrogate decision maker; theories; trend; uptake; urban residence; virtual; willingness

Project Summary/Abstract Although the use of palliative and hospice care for terminally ill Medicare patients is growing, large numbers of Americans die following intensive, non-curative, burdensome treatments. Available evidence suggests that advanced care planning (ACP) discussions are associated with less aggressive end-of-life (EOL) care, greater concordance between the care patients prefer and the care they receive, and perhaps improved bereavement outcomes for caregivers. However, national data on the uptake and impact of ACP are lacking. As a result of a new policy from the Centers for Medicare & Medicaid Services (CMS), effective January 1, 2016, clinicians may now bill for having ACP discussions with their patients. This provides an unprecedented opportunity to study the use and impact of these discussions on a national population basis. Importantly, these services are reimbursable whether they are provided by physicians or nurses in any setting. The proposed study will use both quantitative and qualitative methods to provide a unique scientific examination of the use of ACP discussions and their impact on the intensity and outcomes of care received by seriously ill patients nearing the end of life. We propose the following aims: Aim 1) To identify trends in use and factors associated with Medicare ACP discussions. Using Medicare claims files, we will examine the number and types of patients who have ACP discussions documented by their clinicians, factors associated with ACP use, and trends over time in ACP uptake. Aim 2) To examine the impact of ACP discussions on EOL intensity among seriously ill patients. Using Medicare claims files, we will build a prospective cohort of seriously ill patients and examine the effect of ACP conversations on patients' EOL intensity. Aim 3) To identify barriers and facilitators of conducting ACP discussions in clinical settings. Using qualitative methods (case studies, focus groups, semi-structured interviews), we will examine patients', clinicians', and other stakeholders' perceived barriers and facilitators to the use of ACP, as well as explore implications of ACP conversations with respect to clinical workflow. It is hoped that by further understanding utilization patterns of ACP use and accompanying barriers and facilitators to implementation may influence patient care. We expect that the findings of the proposed analyses will serve to advise health systems and policymakers on how best to direct resources and address potential inequities relating to ACP conversations and, more broadly, inform the viability of targeting ACP as a primary vehicle for change, as opposed to other aspects of the EOL care delivery system.

项目摘要/摘要 尽管对临终病人的姑息和临终关怀的使用正在增加，但大量的 的美国人死于强化的、非根治的、繁重的治疗。现有证据表明 高级护理计划(ACP)的讨论与不那么激进的临终关怀(EOL)相关， 患者更喜欢的护理与他们所接受的护理之间的一致性，可能还会改善丧亲状况 照顾者的结果。然而，缺乏关于非加太的吸收和影响的国家数据。 由于医疗保险和医疗补助服务中心(CMS)1月1日生效的一项新政策， 2016年，临床医生现在可以为与患者进行ACP讨论而收费。这提供了前所未有的 有机会研究这些讨论在国家人口基础上的使用和影响。重要的是，这些 无论是由医生还是护士在任何环境下提供的服务都是可报销的。 建议的研究将使用定量和定性的方法，以提供独特的科学 审查非加太项目讨论的使用情况及其对以下机构接受护理的强度和结果的影响 生命垂危的重病患者。我们提出以下目标： 目的1)确定与Medicare ACP讨论相关的使用趋势和因素。vbl.使用 Medicare索赔文件，我们将检查有ACP讨论的患者的数量和类型 由他们的临床医生记录，与ACP使用相关的因素，以及随着时间的推移ACP摄取的趋势。 目的2)探讨ACP讨论对危重患者生命周期强度的影响。 使用联邦医疗保险索赔文件，我们将建立一个重病患者的预期队列，并检查 ACP对话关于患者的EOL强度。 目的3)找出在临床环境中进行ACP讨论的障碍和促进者。vbl.使用 定性方法(案例研究、焦点小组、半结构访谈)，我们将检查患者的、 临床医生和其他利益相关者对使用ACP的感知障碍和促进者，以及探索 ACP对话对临床工作流程的影响。 希望通过进一步了解ACP使用的使用模式和伴随的障碍和 实施的促进者可能会影响患者护理。我们期望拟议的分析结果 将就如何最好地引导资源和应对潜在问题向卫生系统和政策制定者提供建议 与非加太对话有关的不平等，更广泛地说，说明了将非加太作为主要目标的可行性 变革的载体，而不是EOL护理提供系统的其他方面。