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，关于开始透析的决策受到沟通不畅和缺乏对ESRD管理选项的理解的影响。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相关，但可能与更差的生活质量相关。然而，关于老年人在开始透析后以患者为中心的结局（如功能状态和认知功能）方面的预期却知之甚少。此外，即使关于透析开始的选择涉及透析的潜在寿命增益与保守管理的潜在更好的生活质量之间的一系列困难的权衡，但很少有关于患者、家庭和临床医生对该决策过程的观点的研究，并且很少有资源可以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且互补的目标，旨在解决与透析决策相关的这些挑战：1）与未接受透析的成人的轨迹相比，定义70岁及以上ESRD成人在开始透析前后的功能状态和认知功能轨迹。2)探讨在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（与最大保守治疗相比）的观点。3)开发和试点测试决策辅助工具 针对有决策能力的即将发生ESRD的老年患者及其家人，旨在提高对透析和保守管理选项的了解，并提高对个人价值观和治疗偏好的清晰度。 第一个项目是使用来自健康和退休研究的全国代表性纵向调查数据进行定量分析，与医疗保险索赔有关。第二个项目的特点是定性的半结构化访谈患者，家庭成员和临床医生谁是在不同的点在决策过程中（之前和之后决定透析）。第三个项目将利用从目标1和2中获得的知识，为预计在12个月内需要透析的70岁及以上有决策能力的成年人设计决策辅助工具，并将对患者进行试点测试。目标3的结果将为决策辅助的随机对照试验的R 01提案提供初步数据。 K23职业发展奖的总体目标是支持哈佛医学院的姑息治疗医生和卫生服务研究员Melissa Wachterman博士的早期职业生涯。Wachterman博士是一位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研究员，进行研究，提高护理质量和以患者为中心的治疗决策，为患有严重疾病的老年人及其家人。Wachterman博士先前对患有慢性疾病（如痴呆症）的老年人的临终关怀的研究，以及她最近的工作，探索老年患者在讨论预后时对透析和肾病学家与患者之间沟通障碍的看法。 该K23奖将帮助Wachterman博士实现以下目标：1）获得生物统计学和流行病学的高级培训，包括使用纵向全国代表性调查数据和管理数据的分析技能; 2）获得定性研究方法的高级培训; 3）了解共同决策的理论框架，并发展决策辅助开发和评估的技能; 4）发展为一名调查员，以确保从这个职业发展奖成功过渡到独立的R 01级资助。 为了实现这些目标，Wachterman博士选择了一个指导团队，致力于她作为临床研究者的成功，利用她在哈佛医学院附属的三个领先的学术医疗中心的联合任命：Brigham and Women's Hospital，VA Boston Healthcare System和Dana Farber Cancer Institute。她的主要导师是Nancy Keating博士，她是哈佛医学院医学和卫生政策副教授，也是国际公认的具有姑息治疗专业知识的卫生服务研究员。她的共同导师是Edward Marcantonio博士，他是一位老年病学家，也是国际知名的衰老研究临床研究者。为了补充Keating博士和Marcantonio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，以提供定性研究，决策科学，肾脏学和生物统计学方面的额外知识和经验。她还得到了一个指导委员会的支持，该委员会由具有与她的建议相关的专门知识的全国知名领导人组成。总的来说，Wachterman博士将从哈佛充满活力的研究社区工作中受益匪浅，这将为她提供熟练的指导和支持，因为她准备开始她作为一名独立研究者的职业生涯。