Impact of federal policies on disparities at the end of life care among nursing home residents with Alzheimer's diseases or related dementia

项目摘要 在老年痴呆症疗养院（NH）居民中，临终（EOL）护理的种族差异继续存在。 疾病和相关痴呆症（ADRD）。最近的研究报告称，患有痴呆症的黑人NH居民 更有可能接受积极的EOL护理，包括住院治疗，ER访视，喂食管和积极的 药物治疗，与白人相比。ADRD是一种进行性的、限制生命的综合征， 治疗因此，临终关怀是更可取的老年人与ADRD在EOL，因为它优先考虑 通过减少疼痛和痛苦来提高生活的舒适度和质量。医疗保险是患者的主要保险人， ADRD并涵盖所有预后6个月或更短的临终关怀。大约90%的美国老年人 ADRD在死亡前被放置在NH中，对于医疗保险政策制定者来说，理解这一点至关重要 在NHS临终关怀中的种族差异的当代特征，以实施有效的政策 促进健康公平。最近，人们对欺诈/不适当的患者选择表示担忧 有利于长期住院患者的做法，特别是ADRD患者，因为长期临终关怀的患者 住院为收容所带来了更大的利润。为了阻止长期住院患者选择临终关怀，医疗保险 推出了2014年改善医疗保险后急性护理转型（IMPACT）法案，以授权审计 有针对性的收容所，病人住院时间超过180天的比例很高。它仍然没有解决如何 在患有ADRD的NH居民中实施IMPACT，种族差异发生变化。 该项目的总体目标是改善NH ADRD居民的EOL健康公平性。R01的目标 建议是确定IMPACT对患有ADRD的NH居民临终关怀中种族差异的影响， 并描述最有可能经历不充分临终关怀的亚组。主 假设是，种族差异在EOL护理持续增加后，IMPACT实施。我们将 采用混合方法来实现以下目标（A）和假设（H）： A1.研究IMPACT对NH ADRD居民临终关怀中种族差异的影响。 A2.根据多项指标，描述具有ADRD高风险的NH居民的表型， 很短或很长的临终关怀，并比较这些表型之间的黑人和白色居民。 A3.获得护理提供者的观点在NHS关于临终关怀政策如何可能影响临终关怀 ADRD患者的护理转介。一个由临床顾问组成的专家小组将确定 临终关怀转介，以及医疗保险政策可以减少他们的潜在机制。 这项研究将评估医疗保险政策对种族差异的临终关怀之间的非常脆弱的 人群：居住在NH的ADRD老年人。结果还将确定这些人的亚组 临终关怀护理不充分的风险很高研究结果将支持临床医生了解干预措施如何 减少种族差异和提高健康公平性的目标可以针对高危群体中的个人。

Project Summary Racial disparities in end-of-life (EOL) care continue to persist in nursing home (NH) residents with Alzheimer’s disease and related dementia (ADRD). Recent studies reported that black NH residents with dementia were more likely to receive aggressive EOL care, including hospitalizations, ER visits, feeding tubes and aggressive medication therapy, compared to Whites. ADRD is a progressive, life-limiting syndrome without a curative treatment. Hence, hospice care is preferable for older adults with ADRD during EOL because it prioritizes comfort and quality of life by reducing pain and suffering. Medicare is the primary insurer of patients with ADRD and covers hospice for all with a 6-months or shorter prognosis. As about 90% of older Americans with ADRD are placed in NHs before death, it is critically important for Medicare policy makers to understand contemporary characteristics of racial disparities in hospice care in NHs in order to implement efficient policies to promote health equity. Recently, there raised concerns about fraudulent/inappropriate patient selection practices that favored long-stay patients, particularly ADRD patients, because patients with longer hospice stays generated greater profits for hospices. To discourage hospice selection for long-stay patients, Medicare launched the 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act to mandate auditing targeted hospices with high proportion of patient staying longer than 180 days. It remains unaddressed how racial disparities change with implementing IMPACT in NH residents with ADRD. The project’s overall goal is to improve EOL health equity for NH residents with ADRD. The aims for this R01 proposal are to identify the effects of IMPACT on racial disparities in hospice care in NH residents with ADRD, and to characterize subgroups that are most likely to experience inadequate hospice care. The primary hypothesis is that racial disparities in EOL care increased persistently after IMPACT was implemented. We will employ mixed methods to accomplish the following aims (A) and hypotheses (H): A1. To examine impacts of IMPACT on racial disparities in hospice care in NH residents with ADRD. A2. To characterize phenotypes of NH residents with ADRD based on multimorbidity who have high risks for very short or very long hospice care, and compare these phenotypes between Black and White residents. A3. To obtain perspectives of care providers in NHs about how hospice polices may influence hospice care referrals among residents with ADRD. An expert panel of clinical advisors will identify barriers to hospice care referrals, and potential mechanisms through which Medicare policies could reduce them. This study will evaluate Medicare policy on racial disparities in hospice care among a very vulnerable population: older adults with ADRD who reside in NHs. Results will also identify subgroups of these individuals at high risk of inadequate hospice stays. Findings will support clinicians with insight about how interventions to reduce racial disparities and improve health equity can be targeted to individuals in high-risk groups.