Explaining Variations in End-of-Life Care Intensity

描述(由申请人提供)：医疗保健支出占美国国内生产总值的17.3%，并不成比例地分配给临终关怀(EOL)。这在很大程度上是由于在生命的最后几个月大量使用服务(住院、机械通风)造成的。然而，数据表明，接受治疗的绝症患者 积极的EOL护理比其他患者的生活质量更差。需要进行研究以确定影响EOL护理强度的因素。大量证据表明，美国各地EOL的护理强度和卫生保健支出存在显著的地区差异。研究还表明，种族/民族和卫生系统在EOL护理方面存在显著差异。现有数据没有足够的细节、差异或大小来评估患者、医生和卫生系统因素在多大程度上解释了地区差异，也没有评估EOL护理中的种族/民族差异是否可以通过患者信念和其他因素的差异来解释。特征、医生的执业风格、接受治疗的医院或地区执业模式。我们将使用癌症护理结果和研究监测(CanCORS)联盟的数据，这是一项多地区前瞻性研究，调查了2003-2005年间向人口和基于卫生系统的10,000多名确诊为肺癌或结直肠癌的患者提供的护理。我们将使用CanCORS的患者调查数据、医疗记录数据和医生调查数据，以及来自Medicare、私人健康计划、Medicaid和退伍军人管理局的管理数据，检查2012年前跟踪的4000多名晚期肺癌或结直肠癌患者的EOL护理强度。我们将使用分层模型来评估影响EOL护理强度的患者、医生、医院和地区因素。具体地说，我们将：1.用护理强度和对预期确诊的晚期癌症患者的支出的衡量来验证达特茅斯对EOL支出的回溯性衡量。2.了解造成EOL护理强度地区一级差异的因素，包括患者和肿瘤特征(例如，人口统计数据、并存疾病、转移部位)、患者信念(例如， (例如，对延长生命护理的偏好、对化疗对晚期癌症有效性的信念)、医生的执业风格和信念(例如，对晚期癌症患者更多地使用化疗、自我报告的时间安排和对EOL讨论的舒适性、个人对晚期疾病的临终关怀的偏好)、医院的特点和执业模式，以及服务的可用性。3.在地区内，评估患者、医生和医院的差异在多大程度上解释了EOL护理强度的种族/民族差异。4.了解医疗系统(按服务收费的联邦医疗保险、联邦医疗保险管理的医疗保健，VA)中EOL护理强度的差异，并跨系统评估患者和医生的特征和信念。 公共卫生相关性：这项研究将扩大我们对晚期癌症患者临终关怀高支出和高强度的因素的理解，并将有助于为解决临终关怀差距的战略确定适当的目标。如果EOL护理强度的差异主要是由医生、当地实践模式和服务的可获得性(例如重症监护床位)驱动的，研究结果将确定干预机会，以确保患者在EOL获得与他们的偏好相匹配的护理，并将确定在此类护理不受患者偏好驱动的地区降低护理强度的机会。如果高强度的EOL护理是由患者的偏好驱动的，那么重要的是评估这些是否是知情偏好，以及，我不是，它们是否可以成为知情偏好(例如，可以通过EOL讨论来修改的偏好)。

DESCRIPTION (provided by applicant): Health care expenditures account for 17.3% of gross domestic product in the United States and are disproportionately allocated to care at the end-of-life (EOL). Much of this results from intensive use of services (hospitalizations, mechanical ventilation) in the last months of life. Yet, data suggest that terminally-ill patients who receive aggressive EOL care have worse quality of life than other patients. Research is needed to determine the factors that contribute to the intensity of EOL care. A large body of evidence demonstrates substantial regional variations in intensity of care and health care spending at the EOL across the U.S. Studies have also demonstrated notable differences in EOL care by race/ethnicity and health systems. Available data have not had sufficient detail, variation, or siz to assess the extent to which area variations are explained by patient, physician, and health system factors, nor to assess if racial/ethnic disparities in EOL care can be explained by differences in patients' beliefs and other. characteristics, physicians' practice styles, the hospitals where care is received, or area practice patterns. We will use data from the Cancer Care Outcomes and Research Surveillance (CanCORS) Consortium, a multi-regional prospective study examining care delivered to population and health-system based cohorts of more than 10,000 patients diagnosed with lung or colorectal cancer during 2003-2005. We will use CanCORS patient survey data, medical record data and physician survey data linked with administrative data from Medicare, private health plans, Medicaid, and the VA to examine the intensity of EOL care among over 4,000 patients with advanced lung or colorectal cancer followed through 2012. We will use hierarchical models to assess the patient, physician, hospital, and area factors influencing intensity of EOL care. Specifically, we will: 1. Validate th retrospective Dartmouth measures of EOL spending with measures of care intensity and expenditures for prospectively identified patients with advanced cancer. 2. Understand the factors contributing to area-level variations in intensity of EOL care, including patient and tumo characteristics (e.g., demographics, comorbid illness, site of metastases), patient beliefs (e.g., preferences for life-prolonging care, beliefs about the effectiveness of chemotherapy for advanced cancer), physician practice style and beliefs (e.g., greater use of chemotherapy for advanced cancer patients, self- reported timing and comfort with EOL discussions, personal preference for hospice if terminally-ill), hospital characteristics and practice patterns, and are service availability. 3. Within areas, assess to what extent racial/ethnic differences in intensityof EOL care are explained by patient, physician, and hospital differences. 4. Understand differences in intensity of EOL care across health system (fee-for-service Medicare, Medicare managed care, VA), and assess patient and physician characteristics and beliefs across systems. PUBLIC HEALTH RELEVANCE: This study will expand our understanding of the factors contributing to the high expenditures and intensity of end-of-life (EOL) care for individuals with advanced cancer and will help to identify the appropriate targets for strategies to address disparities in EOL care. If differences in EOL care intensity are primarily driven by physicians, local area practice patterns, and availability of services (e.g., intensive care beds), the finding will identify opportunities for interventions to assure that patients obtain care at the EOL that matches their preferences, and it will identify opportunities to decrease intensity of care in area where such care is not driven by patients' preferences. If high-intensity EOL care is driven by patients' preferences, then it will be important to assess if these are informed preferences and, i not, whether they can become informed preferences (e.g., preferences that may be modifiable through EOL discussions).