Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia

晚期痴呆老年人护理中临床动力标志物的表征和识别

• 批准号: 10041036
• 负责人: Margaret Schwarze
• 金额: $ 23.25万
• 依托单位: UNIVERSITY OF WISCONSIN-MADISON
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-09-30 至 2022-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10041036
• 关键词: Acute; Address; Adult; Affect; Anthropology; Award; Behavioral; Caring; Case Manager; Case Study; Characteristics; Clinical; Clinical Markers; Communication; Decision Making; Deglutition; Dementia; Development; Diagnosis; Elderly; Electronic Health Record; Enteral Feeding; Environment; Event; Failure; Family member; Future; Gastrostomy; Goals; Health Care Costs; Hospitalization; Hospitals; Human Resources; Incentives; Institution; Intensive Care; Intervention; Interview; Language; Lead; Length of Stay; Life; Link; Measures; Medical; Medical Records; Methods; Modeling; Nurses; Nursing Homes; Observational Study; Outcome; Palliative Care; Pathologist; Patient Care; Patients; Pattern; Patterns of Care; Physicians; Play; Policy Maker; Population; Positioning Attribute; Prevalence; Process; Property; Psychology; Quality of Care; Quality of life; Research; Research Proposals; Resources; Risk; Role; Signs and Symptoms; Specialist; Speech; System; Testing; Time; Tube; Universities; Wisconsin; Work; acute care; advanced dementia; base; biomarker identification; care delivery; chemotherapy; clinical care; clinical effect; design; driving force; end of life; end of life care; experience; feeding; financial incentive; improved; informant; innovation; multidisciplinary; overtreatment; patient population; practice setting; preference; public health priorities; skills; theories; tool; treatment risk

ABSTRACT In the final 6 months of life older adults with serious illness will frequently receive invasive treatments despite preferences to avoid burdensome interventions with limited efficacy. For example, feeding tubes are not recommended for older adults with advanced dementia, but nearly one in ten will receive one. Strategies to reduce receipt of overtreatment at the end of life have focused largely on improving communication, yet systems-level practice patterns have a strong influence on the delivery of patient care. Upstream events and clinical norms can produce a trajectory of care that is difficult to modify even with the advanced communication skills employed by palliative care specialists. “Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia” is a two-year observational study that responds specifically to PA-18-503 for an exploratory or developmental research proposal to develop new tools, methods and models focused on palliative care in geriatric populations. Our research team has previously recognized systems-level practice patterns leading to overtreatment and developed a conceptual framework to describe this phenomenon that we call clinical momentum. We now need to develop empirical tools to identify and measure clinical momentum and document its relationship to overtreatment at the end of life. The objective of this proposal is to characterize the trajectory of care for older adults with advanced dementia who have a feeding tube placed during acute hospitalization as a case study of clinical momentum. This 2-part study is designed to evaluate and extend our conceptual framework by characterizing components of clinical momentum in practice and identifying markers of clinical momentum in the electronic health record. For aim 1, we will use key informant interviews and qualitative analysis to describe the trajectory of events, processes, and latent properties of acute care that lead to feeding tube placement for patients with advanced dementia. For aim 2, we will identify markers and the sequence of events generating clinical momentum that are evident in the medical record. Upon completion of this work we hope to have a deep understanding of the trajectory of care that leads to feeding tube placement in adults with advanced dementia. This research is innovative because it uses a theory-driven empirical strategy to identify practice patterns that may play a critical role in the provision of overtreatment at the end of life. This research is significant because characterizing clinical momentum could allow us to identify misaligned incentives and specific moments earlier in the trajectory of care where interventions could be employed to disrupt clinical momentum and improve the quality of care for older adults. Our multidisciplinary team is well positioned to achieve our objectives within the scope of this award given the resources in our environment, allowing us to examine this problem within 2 distinctly different hospital settings.

摘要 在生命的最后6个月，患有严重疾病的老年人将经常接受侵入性治疗， 优先选择避免效率有限的繁琐干预措施。例如，喂食管不是 推荐给患有晚期痴呆症的老年人，但近十分之一的人会接受这种治疗。的战略 减少在生命结束时接受过度治疗主要集中在改善沟通上， 系统级实践模式对患者护理的提供有很大影响。上游事件和 临床规范可能会产生一种即使有先进的沟通也难以修改的护理轨迹 姑息治疗专家所使用的技能。 “老年人护理中临床动力标志物的表征和鉴定 “晚期痴呆症”是一项为期两年的观察性研究，对PA-18-503有特异性反应， 探索性或发展性研究提案，以开发新的工具、方法和模型，重点是 老年人的姑息治疗。我们的研究团队之前已经认可了系统级实践 导致过度治疗的模式，并制定了一个概念框架来描述这种现象， 称为临床动力。我们现在需要开发经验工具来识别和测量临床动力 并记录其与临终时过度治疗的关系。这项建议的目的是 描述老年痴呆症晚期患者的护理轨迹， 在急性住院期间作为临床动力的案例研究。本研究分为两部分，旨在评估 并通过在实践中表征临床动力的组成部分来扩展我们的概念框架， 识别所述电子健康记录中的临床势头的标记。对于目标1，我们将使用关键线人 访谈和定性分析，以描述事件的轨迹，过程和潜在的属性， 急性护理，导致喂食管放置晚期痴呆症患者。对于目标2，我们将确定 标记和事件序列产生的临床势头是明显的医疗记录。 在完成这项工作后，我们希望能够深入了解护理的轨迹， 晚期痴呆成年患者的饲管放置。这项研究是创新的，因为它使用了 理论驱动的实证战略，以确定实践模式，可能发挥关键作用，提供 生命尽头的过度治疗这项研究意义重大，因为表征临床动力可以 使我们能够在护理轨迹的早期确定不一致的激励措施和特定时刻， 可以采取干预措施，扰乱临床势头，提高老年人的护理质量。 我们的多学科团队有能力在这个奖项的范围内实现我们的目标， 资源，使我们能够在两个截然不同的医院环境中研究这个问题。