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

项目总结/摘要 虽然姑息治疗和临终关怀的使用末期疾病的医疗保险病人越来越多， 的美国人死于密集的、非治愈性的、负担沉重的治疗。现有证据表明， 高级护理计划（ACP）讨论与不太积极的临终（EOL）护理相关， 病人喜欢的护理和他们接受的护理之间的一致性，也许可以改善丧亲之痛 照顾者的结果。然而，缺乏关于非加太国家接受情况和影响的国家数据。 由于医疗保险和医疗补助服务中心（CMS）的一项新政策，1月1日生效， 2016年，临床医生现在可以与患者进行ACP讨论。这提供了前所未有的 有机会在全国人口的基础上研究这些讨论的用途和影响。重要的是这些 无论是医生还是护士在任何情况下提供的服务都是可偿还的。 拟议的研究将使用定量和定性方法， 检查ACP讨论的使用及其对护理强度和结果的影响， 接近生命尽头的重病患者。我们提出以下目标： 目的1）确定使用趋势和与Medicare ACP讨论相关的因素。使用 医疗保险索赔文件，我们将检查有ACP讨论的患者的数量和类型 由临床医生记录，与ACP使用相关的因素以及ACP摄取随时间的趋势。 目的2）检查ACP讨论对重症患者EOL强度的影响。 使用医疗保险索赔文件，我们将建立一个重病患者的前瞻性队列，并检查 关于患者EOL强度的ACP对话。 目的3）确定在临床环境中进行ACP讨论的障碍和促进因素。使用 定性方法（案例研究，焦点小组，半结构化访谈），我们将检查患者的， 临床医生和其他利益相关者认为使用ACP的障碍和促进因素，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非加太使用的使用模式和伴随的障碍， 实施的促进者可能会影响患者护理。我们希望拟议分析的结果 将为卫生系统和决策者提供建议，指导资源的最佳使用， 与ACP对话有关的不公平现象，更广泛地说，将ACP作为主要目标的可行性 这是一种变革的工具，而不是EOL护理提供系统的其他方面。

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.