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 在患有阿尔茨海默氏症的养老院(NH)居民中，临终关怀(EOL)方面的种族差异继续存在 疾病和相关痴呆(ADRD)。最近的研究报告说，患有痴呆症的NH黑人居民 更有可能接受积极的生命周期护理，包括住院、急诊室就诊、喂养管和积极的 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，没有根治的方法 治疗。因此，临终关怀对于患有ADRD的老年人来说是更可取的，因为它优先考虑 通过减少痛苦和痛苦来舒适和提高生活质量。联邦医疗保险是符合以下条件的患者的主要保险公司 ADRD和覆盖所有预后为6个月或更短的临终关怀。大约90%的老年美国人患有 ADRD在死前被放入NHS，对于联邦医疗保险政策制定者来说，了解 英国国民健康保险制度临终关怀中种族差异的当代特征 促进健康公平。最近，人们对欺诈性/不适当的患者选择表示担忧 有利于长期住院患者，特别是ADRD患者的做法，因为患者的临终关怀时间更长 住宿为临终关怀带来了更大的利润。为了不鼓励长期住院患者选择临终关怀，联邦医疗保险 启动2014年改善医疗保险急性护理转型后(IMPACT)法案，要求进行审计 有针对性的临终关怀，患者住院时间超过180天的比例很高。它仍然没有解决如何 种族差异随着对患有ADRD的NH居民实施影响而改变。 该项目的总体目标是改善患有ADRD的NH居民的EOL健康公平。这款R01的目标 提案是确定对患有ADRD的NH居民在临终关怀方面的种族差异的影响， 并对最有可能经历不充分临终关怀的亚群进行表征。初级阶段 假说是EOL护理中的种族差异在实施影响后持续增加。我们会 使用混合方法来实现以下目标(A)和假设(H)： A1.研究对患有ADRD的NH居民在临终关怀方面的种族差异的影响。 A2.根据高危人群的多发病特征分析非霍奇金淋巴瘤患者ADRD的表型 非常短或非常长的临终关怀，并比较黑人和白人居民的这些表型。 A3.获取NHS中护理人员对临终关怀政策如何影响临终关怀的看法 ADRD患者的护理转诊。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转介的潜在机制。 这项研究将评估在非常脆弱的人群中临终关怀中的种族差异的医疗保险政策 人口：居住在NHS的患有ADRD的老年人。结果还将确定这些人的亚群 临终关怀住院时间不足的风险很高。研究结果将支持临床医生深入了解干预措施如何 缩小种族差距和改善健康公平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.