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.

抽象的 在生命的最后六个月中，老年人患有严重疾病 避免有限效率的易燃干预措施的偏好。例如，饲管不是 推荐给患有晚期痴呆症的老年人，但几乎十分之一的人会接受。策略 减少生命末期过度治疗的收到主要集中于改善沟通，但 系统级实践模式对患者护理的提供有很大的影响。上游事件和 临床规范可以产生护理轨迹，即使进行高级交流也很难修改 姑息治疗专家使用的技能。 “在老年人护理中的临床动量标记的表征和鉴定 高级痴呆”是一项为期两年的观察性研究，专门针对PA-18-503的响应 探索性或发展研究建议，以开发针对的新工具，方法和模型 老年人群的姑息治疗。我们的研究团队以前已经认可了系统级实践 导致过度治疗的模式并开发了一个概念框架来描述我们的现象 调用临床动量。现在，我们需要开发经验工具来识别和测量临床动量 并记录其与生命尽头的过度治疗的关系。该提议的目的是 表征患有喂养管的晚期痴呆症的老年人的护理轨迹 在急性住院期间，作为临床动量的案例研究。这项两部分研究旨在评估 并通过在实践中表征临床动量的组成部分来扩展我们的概念框架 识别电子健康记录中临床动量的标记。对于AIM 1，我们将使用关键线人 访谈和定性分析，以描述事件，过程和潜在特性的轨迹 急性护理，导致晚期痴呆症患者的喂养管。对于AIM 2，我们将确定 标记和事件的顺序产生临床动量，这是病历中的证据。 完成这项工作后，我们希望对导致护理的轨迹有深刻的了解 患有晚期痴呆的成年人的喂养管位置。这项研究具有创新性，因为它使用了 理论驱动的经验策略来识别可能在提供中起关键作用的实践模式 过度治疗生命的尽头。这项研究很重要，因为表征临床动量可以 允许我们在护理轨迹的早些时候确定未对准的激励措施和特定时刻 可以采用干预措施来破坏临床动量并提高老年人的护理质量。 我们的多学科团队在此奖项范围内实现我们的目标良好 我们环境中的资源，使我们能够在两个截然不同的医院环境中检查这个问题。