Deciding about Dialysis: Improving Decision-Making Among Older Adults with ESRD

决定是否进行透析：改善患有 ESRD 的老年人的决策

• 批准号: 9482690
• 负责人: MELISSA WACHTERMAN
• 金额: $ 15.48万
• 依托单位: HARVARD MEDICAL SCHOOL
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-08-15 至 2020-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9482690
• 关键词: Academic Medical Centers; Address; Adult; Aging; Appointment; Biometry; Boston; Caregiver Burden; Chronic Disease; Clinical; Clinical Investigator; Cognitive; Communication; Communication Barriers; Communities; Complement; Complex; Dana-Farber Cancer Institute; Data; Decision Aid; Decision Making; Dementia; Development; Dialysis patients; Dialysis procedure; Disease; Elderly; End stage renal failure; Ensure; Epidemiology; Evaluation; Family; Family member; Funding; Goals; Health Policy; Health Services; Health and Retirement Study; Healthcare Systems; Hearing; Hospitals; Impairment; Individual; International; Interview; Joints; K-Series Research Career Programs; Kidney Failure; Knowledge; Learning; Life; Life Expectancy; Link; Longevity; Longitudinal Surveys; Medical; Medicare; Medicare claim; Medicine; Melissa; Mentored Patient-Oriented Research Career Development Award; Mentors; Mentorship; Modeling; Nephrology; Pain; Palliative Care; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Phase; Physicians; Process; Qualitative Research; Quality of Care; Quality of life; Randomized Controlled Trials; Regrets; Research; Research Methodology; Research Personnel; Resources; Science; Series; Surveys; Symptoms; Talents; Testing; Time; Training; Transition Career Development Award (K22); Woman; Work; aged; burden of illness; career; career development; cognitive function; demographics; design; end of life care; expectation; experience; functional status; health data; improved; longitudinal analysis; medical schools; mid-career faculty; mortality; older patient; outcome forecast; patient oriented; preference; prognostic; public health relevance; reduce symptoms; shared decision making; skills; success; treatment center

 DESCRIPTION (provided by applicant): Individuals 70 and older are the fastest growing group of patients with end-stage renal disease (ESRD). Research shows that decision-making regarding initiation of dialysis is impaired by poor communication and lack of understanding about the options for management of ESRD. Some small studies suggest that, among older adults, dialysis may be associated with longer life expectancy but possibly worse quality of life, compared to conservative management without dialysis. Yet little is known about what older adults can expect after initiating dialysis in terms of patient-centered outcomes such as functional status and cognitive function. Furthermore, even though the choice regarding dialysis initiation involves a series of difficult trade-offs between potential longevity gains with dialysi and potentially better quality of life with conservative management, there has been little research into patient, family, and clinician perspectives on this decision-making process, and very few resources exist to promote decision-making that reflects patients' values and informed treatment preferences. This proposal has the following three interrelated and complementary aims that address these challenges related to dialysis decision-making: 1) Define the trajectories of functional status and cognitive function for adults 70 and older with ESRD before and after initiation of dialysis, compared to the trajectories of adults not on dialysis. 2) Explor perspectives about the decision to initiate dialysis (versus maximum conservative management) among adults 70 and older, their families, and clinicians. 3) Develop and pilot test a decision aid for decisionally-capable older patients with impending ESRD and their families, designed to improve knowledge about dialysis and conservative management options and to improve clarity about one's values and treatment preferences. The first project is a quantitative analysis using nationally-representative longitudinal survey data from the Health and Retirement Study, linked with Medicare claims. The second project features qualitative semistructured interviews with patients, family members, and clinicians who are at different points in the decisionmaking process (before and after deciding about dialysis). The third project will use the knowledge gained from Aims 1 and 2 to inform the design of a decision aid specifically for decisionally-capable adults 70 and older who are expected to need dialysis within 12 months, which will be pilot-tested with patients. The results from Aim 3 will contribute preliminary data to an R01 proposal of a randomized-controlled trial of the decision aid. The overall objective of this K23 Career Development Award is to support the early career of Dr. Melissa Wachterman, a palliative care physician and health services researcher at Harvard Medical School. Dr. Wachterman is a promising junior investigator specializing in research related to geriatric palliative care. Her career goal is to become an independently-funded clinician-investigator conducting research that improves quality of care and patient-centered treatment decision-making for seriously-ill older adults and their families. This proposal builds o Dr. Wachterman's prior research on end-of-life care for older adults with chronic diseases such as dementia and her more recent work exploring older patients' perspectives on dialysis and communication barriers between nephrologists and patients when discussing prognosis. This K23 award will help Dr. Wachterman accomplish the following goals: 1) to obtain advanced training in biostatistics and epidemiology, including analytic skills using both longitudinal nationallyrepresentative survey data and administrative data; 2) to acquire advanced training in qualitative research methods; 3) to acquire an understanding of theoretical frameworks of shared decision-making and develop skills in decision aid development and evaluation; 4) to develop as an investigator to ensure a successful transition from this career development award to independent R01-level funding. To achieve these goals, Dr. Wachterman has chosen a mentoring team committed to her success as a clinician investigator that capitalizes on her joint appointments at three leading academic medical centers affiliated with Harvard Medical School: Brigham and Women's Hospital, VA Boston Healthcare System, and Dana Farber Cancer Institute. Her primary mentor is Dr. Nancy Keating, Associate Professor of Medicine and Health Policy at Harvard Medical School and an internationally-recognized health services researcher with expertise in palliative care. Her co-mentor is Dr. Edward Marcantonio, a geriatrician and internationallyrenowned clinical investigator in aging research. To complement the extensive expertise of Drs. Keating and Marcantonio, Dr. Wachterman has worked closely with them to carefully select a group of talented local advisors to provide additional knowledge and experience in qualitative research, decision science, nephrology, and biostatistics. She has also enlisted the support of a Steering Committee of nationally-known leaders with expertise relevant to her proposal. Overall, Dr. Wachterman will benefit greatly from working in Harvard's vibrant research community, which will provide her with skilled mentorship and support as she prepares to embark on her career as an independent investigator.

 描述(由申请人提供)：70岁及以上的人是终末期肾病(ESRD)患者中增长最快的群体。研究表明，由于沟通不畅和缺乏对终末期肾病治疗方案的了解，有关开始透析的决策受到影响。一些小型研究表明，在老年人中，与不进行透析的保守治疗相比，透析可能与更长的预期寿命有关，但可能会降低生活质量。然而，对于老年人开始透析后以患者为中心的结果，如功能状态和认知功能，人们知之甚少。此外，尽管关于透析开始的选择涉及一系列艰难的权衡，即通过透析获得潜在的寿命收益，以及通过保守的管理可能获得更好的生活质量，但关于这一决策过程的患者、家庭和临床医生角度的研究很少，而且几乎没有资源来促进反映患者价值观和知情治疗偏好的决策。该提案有以下三个相互关联和互补的目标，以应对与透析决策相关的这些挑战：1)确定70岁及以上ESRD患者在开始透析前和透析后的功能状态和认知功能的轨迹，与未进行透析的成年人的轨迹进行比较。2)解释在70岁及以上的成年人、他们的家人和临床医生中决定开始透析(与最大限度的保守治疗相比)的观点。3)开发和试运行决策辅助工具 专为有决断能力的老年终末期肾病患者及其家人设计，旨在提高对透析和保守治疗选择的知识，并提高对个人价值观和治疗偏好的清晰度。第一个项目是使用具有全国代表性的纵向调查数据进行量化分析，这些数据来自健康和退休研究，与医疗保险索赔有关。第二个项目的特点是对处于决策过程不同阶段(决定透析之前和之后)的患者、家庭成员和临床医生进行定性的半结构化访谈。第三个项目将利用从AIMS 1和AIMS 2获得的知识，为专门为具有决策能力的70岁及以上成年人设计决策辅助工具，这些成年人预计在12个月内需要透析，将在患者中进行试点测试。来自AIM 3的结果将为R01关于辅助决策的随机对照试验的提议贡献初步数据。 这个K23职业发展奖的总体目标是支持梅丽莎·瓦赫特曼博士的早期职业生涯，她是哈佛医学院的姑息医生和卫生服务研究员。Wachterman博士是一名有前途的初级研究员，专门从事与老年姑息治疗相关的研究。她的职业目标是成为一名独立资助的临床医生兼研究员，进行研究，为患有重病的老年人及其家人提高护理质量和以患者为中心的治疗决策。这项建议建立在Wachterman博士之前对患有痴呆症等慢性疾病的老年人的临终关怀的研究，以及她最近的工作，她探索了老年患者对透析的看法，以及在讨论预后时肾科医生和患者之间的沟通障碍。 这一K23奖项将帮助Wachterman博士实现以下目标：1)获得生物统计学和流行病学方面的高级培训，包括使用纵向国家统计和流行病学方面的分析技能；2)获得定性研究方法方面的高级培训；3)了解共同决策的理论框架，并发展决策辅助开发和评估方面的技能；4)发展成为一名研究人员，以确保从这个职业发展奖成功过渡到独立的R01级别的资助。 为了实现这些目标，Wachterman博士选择了一个致力于她作为临床研究员取得成功的指导团队，该团队利用她在哈佛医学院附属的三个领先学术医疗中心的联合任命：布里格姆和妇女医院、弗吉尼亚州波士顿医疗系统和Dana Farber癌症研究所。她的主要导师是哈佛医学院医学和卫生政策副教授南希·基廷博士，她是国际公认的卫生服务研究员，拥有姑息治疗方面的专业知识。她的共同导师是爱德华·马尔坎托尼奥博士，他是一位老年病医生，也是衰老研究领域国际知名的临床研究员。为了补充基廷博士和马尔坎托尼奥博士的广泛专业知识，Wachterman博士与他们密切合作，精心挑选了一批有才华的当地顾问，提供定性研究、决策科学、肾脏病和生物统计学方面的更多知识和经验。她还争取到了一个由全国知名领导人组成的指导委员会的支持，这些领导人具有与她的提议相关的专业知识。总体而言，瓦赫特曼博士将从哈佛充满活力的研究界工作中受益匪浅，在她准备开始独立研究生涯之际，这将为她提供熟练的指导和支持。