Developing Real-world Understanding of Medical Music therapy using the Electronic Health Record (DRUMMER)

项目摘要/摘要 几个随机对照试验(RCT)支持音乐疗法(MT)在改善包括癌症、镰状细胞疾病和整形外科手术在内的不同患者群体的疼痛和症状管理方面的有效性。MT是临床上使用定制的音乐干预措施(例如，积极的音乐制作和音乐辅助放松)，以实现由有资格证书的专业人员(即，董事会认证的音乐治疗师)在治疗关系中实现个性化目标。尽管有来自随机对照试验的证据表明MT的有效性，以及MT在临床环境中的递送增加，但很少有临床有效性研究评估MT在卫生系统中的真实影响。评估MT等综合疼痛管理方法是至关重要的，特别是在卫生系统寻求有效的非药物疼痛管理解决方案以降低阿片类药物使用风险的情况下。在了解MT的临床有效性方面仍然存在很大差距。这些研究包括：1)确定与患者报告的结果测量(PROM)变化相关的社会人口学、临床和MT干预特征；2)比较接受MT的患者和接受常规护理的类似患者之间的结果(例如，用药情况和住院时间)；以及3)检查最初MT治疗后对PROM的纵向影响。利用20,405个住院患者中15,460名患者(平均年龄63.6岁，33.5%的黑人/非裔美国人)31,359次MT治疗的大型电子健康记录(EHR)数据集，我建议应用回归模型、倾向-分数匹配和纵向混合效应模型来检查MT的临床有效性。我的具体目标是：目的1)调查哪些人口学特征(例如，年龄和性别)、健康的社会决定因素(例如，保险状况和收入)、临床特征(例如，诊断和护理环境)、和/或MT会话特征(例如，使用的时间长度和MT干预)与胎膜早破的变化(即，压力、疼痛强度、焦虑和应对的0-10个测量)相关；目的2)比较接受MT的住院患者和与倾向得分匹配的对照组之间的结果，包括住院时间、治疗疼痛和焦虑的药物以及纵向疼痛强度评分；探索性目的3)研究在接受MT的患者住院期间对胎膜早破的纵向影响。这项建议将为申请人提供所需的基础知识和经验，以进行未来以实践为基础的临床有效性研究，不仅在MT，而且在卫生系统内部署的多种综合疗法(例如，针灸和按摩疗法)中。随着卫生系统开发基于EHR的质量改进工具并实施非药理性疼痛模式，在该提案中获得的技能对于理解综合健康和医学模式的现实世界影响和改善循证患者护理将特别重要。

PROJECT SUMMARY/ABSTRACT Several randomized controlled trials (RCTs) support the efficacy of music therapy (MT) for improving pain and symptom management in diverse patient populations including cancer, sickle cell disease, and orthopedic surgery. MT is the clinical use of tailored music interventions (e.g., active music making and music-assisted relaxation) to accomplish individualized goals within a therapeutic relationship by a credentialed professional (i.e., board-certified music therapist). Despite evidence for MT’s efficacy from RCTs and the increased delivery of MT in clinical settings, few clinical effectiveness studies have evaluated the real-world impact of MT within health systems. Evaluating integrative pain management approaches such as MT is a vital need, especially as health systems seek effective nonpharmacologic pain management solutions to reduce risks stemming from opioid use. Substantial gaps remain in understanding MT’s clinical effectiveness. These include: 1) identifying socio-demographic, clinical, and MT intervention characteristics associated with changes in patient-reported outcome measures (PROMs); 2) comparing outcomes (e.g., medication use and length of stay) between patients receiving MT and similar patients receiving usual care; and 3) examining longitudinal effects on PROMs beyond the initial MT session. Using a large electronic health record (EHR) dataset of 31,359 MT sessions provided to 15,460 patients (mean age 63.6 years, 33.5% Black/African American) across 20,405 hospital admissions, I propose applying regression models, propensity-score matching, and longitudinal mixed effects models to examine the clinical effectiveness of MT. My Specific Aims are: AIM 1) investigate which demographic characteristics (e.g., age and sex), social determinants of health (e.g., insurance status and income), clinical characteristics (e.g., diagnoses and care setting), and/or MT session characteristics (e.g., length and MT interventions utilized) are associated with changes in PROMs (i.e., 0-10 measures of stress, pain intensity, anxiety, and coping); AIM 2) compare outcomes including length of stay, medications administered for pain and anxiety, and longitudinal pain intensity scores between inpatients receiving MT and propensity-score matched controls; and EXPLORATORY AIM 3) examine longitudinal effects on PROMs over the course of hospital admissions among patients receiving MT. This proposal will provide the applicant with foundational knowledge and experience needed to conduct future practice-based clinical effectiveness research not only in MT, but across multiple integrative therapies (e.g., acupuncture and massage therapy) deployed within health systems. As health systems develop EHR-based quality improvement tools and implement nonpharmacologic pain modalities, the skills acquired within this proposal will be especially important for understanding the real-world impact of integrative health and medicine modalities and improving evidence-based patient care.