Improving Care for Older Adults with Serious Illness

描述（由申请人提供）：该提案代表了一个为期五年的课程和研究计划，旨在促进我在面向患者的老龄化研究方面的独立研究者的发展。在五年的奖项，我将扩大我的卫生服务研究培训和经验，通过指导研究，正式课程，和自主学习活动，并通过领导和网络机会发展独立性。随着老年人口的扩大，美国目前的医疗支出速度是不可持续的。医院服务占医疗保险费用的最大部分，其中大部分用于特定的患者群体：患有严重疾病的老年人。地理区域在医院使用的强度上差异很大，一些人认为这代表了自由裁量或不必要的医院护理。以寿命、生活质量和满意度来衡量，消费的增加也与生活质量的提高无关。了解导致高危老年人不必要住院的因素对于开发成功的高效、以患者为中心的护理新模式至关重要。因此，我的研究目标是前瞻性地识别有高成本医院护理风险的重病老年人，并确定潜在可避免的住院治疗的“触发因素”和这些患者留在社区的障碍。具体来说，我计划：（SA1）在我之前的工作的基础上，通过使用死亡率随访设计，检查健康与退休研究（HRS）队列中生命最后一年医院支出、住院人数和高强度医院治疗的决定因素；（SA2）通过评估与医院支出、住院次数和治疗强度相关的因素来扩展我早期的发现，这些因素在一组重病老年人中与1年死亡率风险前瞻性匹配；（SA3）通过对患者、护理人员和初级保健医生进行定性访谈，调查重症老年人多次住院的原因和医院外管理的障碍，支持制定干预措施，以减少有风险的老年人不必要的住院。拟议的工作使用区域、患者水平和索赔数据的创新组合来评估驱动该人群治疗强度的因素；采用传统的死亡率随访研究设计和新颖的前瞻性分析技术检查结果；并采用混合方法，从患者和家属那里了解导致过度住院的问题，以及如何克服这些挑战。通过我目前的工作和未来的独立研究，我计划创建一个以患者为中心的干预措施，以减少重病老年人不必要的住院治疗，并将我的工作转化为有效的医疗保健政策和临床项目。拟议的研究和职业发展计划是通过改善面对严重疾病的医疗决策和促进更好地将治疗与患者偏好结合起来的政策，来推进老年人护理的重要的第一步。

DESCRIPTION (provided by applicant): This proposal represents a five-year curriculum and research plan designed to facilitate my development to an independent investigator in patient-oriented aging research. During the five years of the award, I will expand on my health services research training and experience through mentored research, formal coursework, and selfdirected learning activities and develop independence through leadership and networking opportunities. The current pace of U.S. healthcare spending is unsustainable as the oldest segments of the population expand. Hospital services account for the largest portion of Medicare costs, the bulk of which goes to a specific patient population: older adults with serious illness. Geographic regions vary widely in their intensity of hospital use and some argue this represents discretionary or unnecessary hospital-based care. Increased spending is also not associated with higher quality, as measured by longevity, quality of life, and satisfaction. Understanding what factors contribute to unnecessary hospitalizations among at-risk older adults is essential for development of successful new models of efficient, patient-centered care. Thus, the goal of my research is to prospectively identify seriously ill older adults at risk of hih-cost hospital-based care, and identify "triggers" of potentially avoidable hospitalizations and barriers to remaining in the community for these patients. Specifically, I plan to: (SA1) Build upon my prior work by examining determinants of hospital expenditures, number of hospital admissions and high-intensity, hospital-based treatment in the last year of life among the Health and Retirement Study (HRS) cohort using a mortality follow-back design; (SA2) Expand my earlier findings by evaluating factors associated with hospital expenditures, number of hospitalizations and treatment intensity among a cohort of seriously ill older adults matched prospectively by 1-year mortality risk; and (SA3) Support the development of an intervention to reduce unnecessary hospital admissions among at-risk older adults by investigating reasons for multiple hospital admissions and barriers to management outside the hospital among seriously ill older adults by conducting qualitative interviews with patients, caregivers and primary care physicians. The proposed work uses an innovative combination of regional, patient-level and claims data to evaluate factors driving treatment intensity in this population; examines outcomes with both a traditional mortality follow-back study design and a novel prospective analytic technique; and employs mixed methods to learn from patients and families what problems lead to excess hospitalizations and how those challenges might be overcome. Through my current work and future independent research, I plan to create a patient-centered intervention to reduce unnecessary hospitalizations among seriously ill older adults and translate my work to effective health care policies and clinical programs. The proposed research and career development plan are important initial steps toward advancing the care of older adults by improving medical decision making in the face of serious illness and promoting policies that better align treatments with patient preferences. PUBLIC HEALTH RELEVANCE: This research will use innovative methods to prospectively examine factors contributing to unnecessary hospital admissions among at-risk older adults. A critical first step toward reducing unnecessary high-cost hospital-based care, this research will contribute knowledge needed to develop successful new models of efficient, high-quality, preference-driven care for older adults with serious illness and promote health care policies that better align treatments with patient preferences.