Invasive and Non-Invasive Mechanical Ventilation Outcomes in Advanced Dementia

项目摘要 未来十年一个重要的公共政策挑战是如何提供以病人和家庭为中心的护理 对于越来越多的患有阿尔茨海默病和相关痴呆症(ADRD)的美国人来说。这个 拟议的研究小组已经证明，尽管家庭偏爱最大化舒适度的护理， 在生命的最后几天，患者往往会接受繁重的治疗和不必要的医疗过渡。 Teno、Gozalo和他的同事在JAMA IM杂志最近发表的一篇论文中指出，机械通风的使用 在过去的十年里，晚期痴呆症患者的发病率一直在上升。在对此进行的初步研究中 应用，我们记录了无创呼吸机的使用量从2006年的仅900例增加到 2013年招生2075人。无创呼吸机(NIV)的应用尚未被研究过 高级ADRD。机械通气在ADRD患者群体中的价值是值得怀疑的 一年死亡率很高，而且大多数家庭更喜欢舒适度最大化的护理。缺乏权威性 有创机械通气对ADRD患者疗效的结果数据。我们之前的研究 晚期痴呆症患者中喂养管的相对有效性对AMDA的贡献， AGS和AAHPM在ABIM选择明智计划中的建议不使用喂养管，而是提供 人工喂养。这项提议的压倒一切的目标是提供权威的、可操作的国家 有创机械通气(IMV)与无创机械通气(NIV)治疗效果比较 通过回答以下问题来解决晚期痴呆症患者：1)什么是时间趋势和 与IMV和NIV使用相关的个人、医院、疗养院和市场特征 2000年至2019年的晚期痴呆患者？2)IMV的相对有效性是什么？ 和/或NIV在治疗晚期ADRD住院患者中的应用 差异倾向匹配？以及3)是否可以创建具有足够区分度的预后模型 校准以向医疗保健专业人员和代理决策者提供可操作的信息？我们的 拟议的研究将是对患有晚期ADRD的IMV和NIV进行的第一次全国性研究。此外， 它将利用来自MDS评估的丰富临床数据来创建具有以下特征的预期队列 高级ADRD，采用新的跨时间倾向匹配方法，并检查IMV的增长 和/或NIV，增强了我们从观察性研究中得出因果推理的能力。获得的知识 这项研究将提供有关IMV和/或NIV在护理人员中的使用的重要信息 先进的ADRD，最终目标是提供基于高价值的护理，尊重患者的权利 对他们的医疗保健做出明智的选择。

Project Summary An important public policy challenge in the coming decade is how to provide patient- and family-centered care for an increasing number of Americans afflicted with Alzheimer's Disease and Related Dementias (ADRD). The proposed research team has documented that, despite family preferences for care that maximizes comfort, patients often receive burdensome treatments and unnecessary health care transitions in the last days of life. A recent publication by Teno, Gozalo, and colleagues in JAMA IM noted that the use of mechanical ventilation in persons with advanced dementia has been increasing over the past decade. In the preliminary study for this application, we document the increase use of non-invasive ventilation from only 900 admissions in 2006 to 2075 admissions in 2013. The use of non-invasive ventilation (NIV) has not been studied in persons with advanced ADRD. The value of mechanical ventilation in a population of ADRD patients is questionable based on high 1-year mortality and that most families prefer comfort-maximizing care. There is a lack of authoritative outcome data on the effectiveness of invasive mechanical ventilation in ADRD patients. Our previous studies of the comparative effectiveness of feeding tubes in persons with advanced dementia contributed to AMDA, AGS, and AAHPM recommendations in the ABIM Choosing Wisely Program to not use feeding tubes but offer hand feeding. The overriding objective of this proposal is to provide authoritative, actionable national information on the outcomes of invasive mechanical ventilation (IMV) and non-invasive ventilation (NIV) in persons with advanced dementia by addressing the following questions: 1) What are the temporal trends and individual, hospital, nursing home, and market characteristics associated with the use of the IMV and NIV in persons with advanced dementia between 2000 and 2019?, 2) What is the comparative effectiveness of IMV and/or NIV in the care of hospitalized persons with advanced ADRD using cross-temporal difference-in- difference propensity matching?, and 3) Can a prognostic model be created with sufficient discrimination and calibration to provide actionable information to health care professionals and surrogate decision makers? Our proposed research will be the first national study of IMV and NIV in person with advanced ADRD. Furthermore, it will capitalize on rich clinical data from MDS assessments to create prospective cohorts of persons with advanced ADRD, employ novel cross-temporal propensity matching methods, and examine the growth of IMV and/or NIV, enhancing our ability to draw causal inferences from an observational study. Knowledge gained from this research will provide important information regarding the use of IMV and/or NIV in the care of persons with advanced ADRD with the ultimate goal of delivering high value-based care that respects patients' rights to make informed choices about their medical care.