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（由应用提供）：70岁及以上的个体是终末期肾脏疾病（ESRD）的成长最快的患者。研究表明，关于透析计划的决策会因沟通不良和对管理ESRD的选择缺乏了解而受到损害。一些小型研究表明，与没有透析的保守管理相比，在老年人中，透析可能与预期寿命更长，但生活质量更差有关。然而，关于老年人在以患者为中心的结果（例如功能状态和认知功能）来启动透析后可以期待什么。此外，即使有关透析计划的选择涉及透析潜在的寿命增长之间的一系列困难权衡，而潜在的透析质量可以通过保守管理进行更好的生活质量，但对患者，家庭和临床观点的研究很少，对这一决策过程的临床观点几乎没有，并且很少有资源来促进决策，以促进对患者的价值观的促进和知识治疗的预期。该提案具有以下三个相互关联和互补的目的，可以解决与透析决策相关的这些挑战：1）与不在透析前后的透析前后，定义了70岁及以上ESRD的成年人的功能状态和认知功能的轨迹，相比之下。 2）关于在70岁及以上的成年人，他们的家庭和临床医生中启动透析（相对于最大保守管理）决定的决定的探索观点。 3）开发和试点测试决策援助 对于具有挑战性的ESRD及其家人的决定性符合能力的老年患者，旨在提高有关透析和保守管理方案的知识，并提高人们对价值观和治疗偏好的清晰度。第一个项目是使用与Medicare索赔有关的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。第二个项目的特点是与患者，家庭成员和临床医生进行定性半结构化访谈，这些访谈在决策过程中处于不同时刻（决定透析之前和之后）。第三个项目将利用AIM 1和2获得的知识来告知专门针对有决策能力的成年人70岁及以上的决策辅助工具，他们有望在12个月内需要透析，这将对患者进行试验。 AIM 3的结果将为R01的提案提供了对决策援助的随机控制试验的建议。 这个K23职业发展奖的总体目标是支持哈佛医学院的姑息治疗物理和卫生服务研究员Melissa Wachterman博士的早期职业。 Wachterman博士是一位有前途的初级研究员，专门研究与老年姑息治疗有关的研究。她的职业目标是成为由独立资助的临床投资者进行研究，以提高护理质量和以患者为中心的治疗决策，以实现认真的老年人及其家人。该提议建立了o瓦克特曼博士先前针对患有慢性疾病的老年人（例如痴呆症）和她最近的工作，探讨老年患者对肾脏医生和患者之间的透析障碍的观点的研究。 这项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，包括使用纵向全国范围的调查数据和行政数据的分析技能； 2）获得定性研究方法的先进培训； 3）了解决策援助制定和评估中共同决策和发展技能的理论框架； 4）作为调查人员发展，以确保从该职业发展奖到独立R01级资金的成功过渡。 为了实现这些目标，Wachterman博士选择了一个心理团队，致力于她作为临床研究人员的成功，该研究人员在哈佛医学院的三个领先的学术医疗中心分支机构（Brigham and妇女医院），VA Boston Healthcare System和Dana Farber Cancer Institute的联合任命。她的主要导师是哈佛医学院医学与卫生政策副教授Nancy Keating博士，也是国际认可的卫生服务研究员，辅助护理专家。她的同事是老年人和国际知名的衰老研究临床研究者爱德华·马坎托尼奥（Edward Marcantonio）博士。完成博士的广泛专业知识。 Keating和Marcantonio，Wachterman博士与他们紧密合作，仔细选择了一群才华横溢的当地顾问，以提供定性研究，决策科学，肾脏病和生物统计学方面的其他知识和经验。她还获得了与她的提议有关的专业知识的指导委员会指导委员会的支持。总体而言，Wachterman博士将在哈佛充满活力的研究社区中工作，这将为她提供熟练的心态和支持，因为她准备着手从事独立调查员的职业。