Impact of POLST Adoption and of Financial Incentives on Care Receipt and on Intensity of Care Preferences in Nursing Home Patients

摘要 繁重的过渡--增加临终关怀强度(EOL)--不一定是人们所希望的 病人或他们的辩护律师。阿尔茨海默病及其相关痴呆(AD/ADRD)患者常见 要求他们的代理人(无论是家人还是其他决策者)确保他们的愿望 相遇了。先前的工作表明，高级指令或其他形式的高级护理计划的存在是 与国家疗养院(NH)人口中较低的EOL繁重过渡率有关。使用 POLST的使用与EOL痴呆症患者中较低的ICU使用率有关。NH质量-AS 以NH比较中的CMS五星评级衡量-与POLST的更高完成率相关 在长期的NH患者中，大多数人筛查有显著的认知障碍。 AD/ADRD患者是一个具有挑战性但适合实施POLST的人群 在生命的尽头减少繁重的过渡。POLST的目标是将患者的意愿编纂成一份 记录医生对护理强度的具体指示的文档。目标是让医疗服务提供者 听从这些命令。AD/ADRD患者高度依赖他人完成和维持POLST 这反映了他们的意愿。 在初步工作中，我们已经证明了NH质量与POLST的完成有关。目前还不太清楚NH是否 质量影响AD/ADRD患者在NH内完成POLST的方式。做质量较低的NHS 完整的POLST反映患者的意愿和/或对其代理人的最佳判断？或者，质量较低 当POLST完成时，NHS默认为更高强度的护理，导致AD/ADRD患者 经历更繁重的过渡，并在生命结束时接受更高强度的护理？ 在这份行政副刊中，我们将调查NH质量对护理偏好和护理的影响 在加利福尼亚州为患有AD/ADRD并在生命末期有严重认知障碍的个人提供分娩服务(2011至 2018)，以具体解决以下具体目标： 1.确定NH质量的总体和组成特征对POLST完井的影响和 LTC AD/ADRD患者临终时的患者偏好。 2.确定NH质量对LTC患者临终时繁重过渡的影响 AD/ADRD在寿命结束时计入POLST完成。 本附录将专门介绍NH质量如何影响患者的完成和记录 一种类型的ACP仪器-POLST-的首选项以及NH质量和POLST如何相互作用 影响AD/ADRD患者在终末期加强护理。

ABSTRACT Burdensome transitions – increases in intensity of care at the end of life (EOL) – are not necessarily desired by patients or their advocates. Patients with Alzheimer’s disease and its related Dementias (AD/ADRD) frequently require the agency of their proxies (whether family or other decision makers) to ensure that their wishes are met. Prior work has shown that existence of an advanced directive or other forms of advanced care planning is associated with lower rates of burdensome transitions at EOL in a national nursing home (NH) population. Use of POLST has been associated with lower ICU use among patients with dementia at EOL. NH quality – as measured by the CMS Five Star Rating in NH Compare – is associated with greater completion of POLST among long term NH patients, most of who screen for significant cognitive impairment. Patients with AD/ADRD represent a challenging, but appropriate population for POLST implementation to reduce burdensome transitions at the end of life. The goal of POLST is to codify patient’s wishes in a single document that captures the physician’s specific orders for care intensity. The goal is for medical providers to follow these orders. Patients with AD/ADRD are highly dependent on others to complete and maintain POLSTs that reflect their wishes. In preliminary work, we have shown that NH quality is associated with POLST completion. It is less clear if NH quality impacts how POLST is completed within NH among patients with AD/ADRD. Do lower quality NHs complete POLSTs that reflect patient wishes and / or the best judgement of their proxies? Or, are lower quality NHs defaulting to higher intensity care when POLSTs are completed, resulting in patients with AD/ADRD undergoing more burdensome transitions and receiving higher intensity care at the end of life? In this administrative supplement, we will investigate the impact of NH quality on care preferences and care delivery for individuals with AD/ADRD with significant cognitive impairment at the end life in California (2011 to 2018) in order to specifically address the following specific aims: 1. Determine the impact of overall and constituent characteristics of NH quality on POLST completion and patient preferences among LTC patients with AD/ADRD at the end-of-life. 2. Determine the impact of NH quality on burdensome transitions at the end-of-life among LTC patients with AD/ADRD at the end-of-life accounting for POLST completion. This supplement will specifically address how NH quality influences the completion and recording of patient preferences in one type of ACP instrument – the POLST – and how NH quality and POLST interact to influence intensification of care at EOL for patients with AD/ADRD.