A Layered Examination of the Patient Experience to Elucidate the Role of Palliative Care in Surgical Care for Seriously Ill Older Adults

项目摘要。 每年有100多万患有严重疾病的老年人(≥65岁)接受大手术或严重创伤。 在手术或创伤后，老年重症患者面临着增加医疗保健使用量、功能和 认知能力下降和死亡率。国家质量指南强调姑息治疗的重点是使 有健康目标的治疗，提高生活质量，减轻身体和心理痛苦，以及 应在提供严重疾病所有阶段的外科护理的同时，提供满足社会需求的医疗服务。姑息疗法 对住院的重病患者的护理与症状的减少和医疗保健的利用有关 出院后。尽管重症手术患者受益于姑息治疗，但他们不太可能 其他住院患者接受它；这在一定程度上是由于研究差距阻碍了实施 为老年重症外科患者提供实用的姑息治疗干预。差距包括缺乏关于 以患者为导向的手术结果，如疼痛、抑郁和护理，可以通过姑息性治疗来实现 护理，外科实践中衡量姑息治疗交付的方法学障碍，以及对此知之甚少 在外科手术中影响姑息治疗实施的环境因素。拟议的研究将 通过提供对姑息治疗在手术中的作用的创新和分层检查来解决这些差距。 这项研究有三个具体目标。目的1确定一组重病老年外科患者(≥66y)，使用 健康和退休研究数据链接到联邦医疗保险索赔，并确定直接 姑息治疗的目标(疼痛、抑郁和护理需求)和较少的近期好处(减少 医疗保健利用)，以证明姑息治疗在外科手术中的重要作用。目标2确定了一个 大型地区性卫生系统中老年重症外科患者(≥66y)的回顾性队列研究 与联邦医疗保险相关的电子健康数据中的自然语言处理，以识别姑息治疗 流程(护理讨论、医疗代理文档、疼痛和护理者评估的目标) 在手术期间接生的。姑息治疗与医疗保健利用之间的关系 手术出院后一年将进行检测。目标3使用定性访谈和直接观察来获得 深入了解影响临终关怀过程实施的背景因素 护理重病的老年外科病人(≥65岁)。该提案使用补充数据源来 评估以患者为中心的老年重症手术患者的结果，使用新方法评估 姑息治疗过程对结果的影响，并深入审查实施 临床实践中的围手术期姑息护理。这些结果将直接为床边临床决策和 实施有针对性的姑息治疗干预以改善老年外科重病患者的护理 病人。

Project Summary . Over 1 million older (≥65 years) adults with serious illness have major surgery or severe trauma each year. After surgery or trauma, older seriously ill patients are at risk for increased healthcare use, functional and cognitive decline, and mortality. National quality guidelines highlight that palliative care focused on aligning treatments with health goals, improving quality of life, alleviating physical and psychological suffering, and addressing social needs, should be provided alongside surgical care at all stages of serious illness. Palliative care for hospitalized seriously ill patients is associated with reduced symptoms and less healthcare utilization after discharge. Although seriously ill surgical patients benefit from palliative care, they are less likely than other hospitalized patients to receive it; this is in part due to research gaps that have inhibited implementation of practical palliative care interventions for older seriously ill surgical patients. Gaps include a dearth of data on patient-oriented surgical outcomes such as pain, depression, and caregiving that can be targeted by palliative care, methodological barriers to measuring palliative care delivery in surgical practice, and little understanding of contextual factors that influence implementation of palliative care in surgery. The proposed study will address these gaps by providing an innovative and layered examination of the role of palliative care in surgery. The study has three specific aims. Aim 1 identifies a cohort of seriously ill older surgical patients (≥66y) using Health and Retirement Study data linked to Medicare claims, and determines the association between direct targets of palliative care (pain, depression, and caregiving needs) and less proximal benefits (reduced healthcare utilization) to demonstrate the important role of palliative care in surgery. Aim 2 identifies a retrospective cohort of older seriously ill surgical patients (≥66y) in a large regional health system and uses Natural Language Processing in electronic health data linked to Medicare Claims to identify palliative care processes (goals of care discussions, healthcare proxy documentation, pain and caregiver assessments) delivered during the surgical episode. The association between palliative care and healthcare utilization in the year after surgical discharge will be tested. Aim 3 uses qualitative interviews and direct observations to obtain an in-depth understanding of contextual factors influencing implementation of palliative care processes in the care of seriously ill older surgical patients (≥65 years). This proposal uses complementary data sources to assess patient-centered outcomes in older seriously ill surgical patients, uses novel methods to evaluate the impact of palliative care processes on outcomes, and deeply examines barriers to implementation of perioperative palliative care in clinical practice. These results will directly inform bedside clinical decisions and the implementation of targeted palliative care interventions to improve care for seriously ill older surgical patients.