Can Concurrent Hospice Care and Cancer Treatment Achieve Superior Outcomes?

描述(由申请人提供)： 这笔赠款的总体目标是告知退伍军人政策制定者在接受临终关怀/姑息治疗的同时向即将死于癌症的退伍军人提供同步护理(疾病修正治疗--化疗和XRT)的效果。这一目标和我们的项目目标与2009年设立的退伍军人管理局姑息治疗倡议的目标高度一致。与联邦医疗保险不同，对于 在过去十年中，退伍军人事务部一直强调发展与姑息治疗和社区临终关怀服务相结合的临床服务，而不必放弃疾病修正治疗(即化疗和放射治疗)。从概念上讲，退伍军人同时进行疾病修正治疗和临终关怀的能力意味着，与联邦医疗保险不同，退伍军人不必做出“可怕的选择”：要么进行疾病修正治疗，要么进行专注于症状控制和完成临终任务的护理。依靠定量和定性相结合的方法，我们试图了解允许晚期癌症退伍军人在临终关怀的同时继续接受疾病修正治疗的成本和好处。基于最近的随机试验证据，我们假设在VAMC集水区新诊断的转移性非小细胞肺癌(NSCLC)退伍军人将比其他情况下更早使用临终关怀和姑息治疗，并在生命的最后几周和几个月内接受更少的“英雄”措施，如ICU入院、重复住院和多次癌症治疗。为了解决这一假设，我们将汇集一个全面的纵向数据库，将2005年至2013年期间所有癌症死者的退伍军人的医疗保健利用率和联邦医疗保险登记和索赔数据合并在一起。基于这些数据，我们将首先描述地区和VAMC在使用退伍军人管理局或联邦医疗保险和/或两者提供的临终关怀/姑息治疗方面的差异。接下来，我们将描述死亡前6个月内每月化疗和XRT的使用率，然后合并这些结果，估计全国同时治疗的流行率，它在不同地区是如何变化的，以及它在过去十年中是如何变化的。然后，使用差异设计，我们将估计VAMC采用并发护理模式对新诊断、转移性、NSCLC患者的退伍军人将经历以下不良医疗服务结果的可能性的影响：1)在生命的最后一个月中有负担的过渡；2)进入临终关怀的时间较晚(&lt；/=死亡前3天)；3)在生命的最后一个月接受疾病修饰的化疗或放射治疗；4)ICU停留在他们生命的最后一周和死亡；以及5)生存。根据VAMC表现出的较高水平与较低水平的并行护理，我们将对这些医疗中心进行现场访问，采访肿瘤学、姑息治疗和护理服务方面的主要信息者，并与当地社区临终关怀领导层和其他感兴趣的各方交谈。使用VA Promise数据库中的近亲调查，我们将在Promise中使用基于声明的繁重过渡来校准生命末期的生活质量评估。最后，使用Promise数据中的生命结束评估质量，我们将对并发护理模型进行正式的成本效益分析。如果这项观察性研究复制了已发表的小规模随机试验，VHA不仅有证据表明更积极地追求同步护理，而且退伍军人管理局准备影响国家在这一主题上的政策。

DESCRIPTION (provided by applicant): The overall goal of this grant is to inform VA policy makers about the effect of offering concurrent care (disease modifying treatment -- Chemotherapy and XRT - while receiving hospice/palliative care) to Veterans dying of cancer. This goal and our project aims are highly consonant with those of the VA Palliative Care Initiative instituted in 2009. Unlike Medicare, for the last decade the Department of Veterans Affairs has emphasized the development of clinical services integrated with palliative care and community hospice services without having to forgo disease modifying treatments (i.e. chemotherapy and radiation). Conceptually, Veterans' ability to concurrently pursue disease modifying treatment and hospice care means that, unlike in Medicare, Veterans do not have to make the "terrible choice" of pursuing either disease modifying treatment or care focused on symptom control and completion of end-of-life tasks. Relying upon a combination of quantitative and qualitative methods, we seek to understand the costs and benefits of allowing Veterans with terminal cancer to continue to receive disease modifying treatment concurrent with hospice care. Based upon recent randomized trial evidence, we hypothesize that Veterans with newly diagnosed, metastatic, non-small cell lung cancer (NSCLC) in VAMC catchment areas that embrace the model of concurrent care for terminal cancer will use hospice and palliative care earlier than might otherwise be the case and will be exposed to fewer "heroic" measures such as ICU admissions, repeated hospitalizations and multiple cancer treatments in the last weeks and months of life. To address this hypothesis we will assemble a comprehensive longitudinal database merging VA health care utilization and Medicare enrollment and claims data for all Veterans who are cancer decedents between 2005 and 2013. Based upon these data, we will first characterize regional and VAMC level differences in the use of hospice/palliative care provided either by VA or Medicare and/or both. Next, we will characterize the rate of use of chemotherapy and XRT per month in the 6 months prior to death and, then, merging these sets of findings, estimate the national prevalence of concurrent treatment, how it varies regionally and how it has changed over the last decade. Then, using a difference in difference design, we will estimate the effect of a VAMC adopting a concurrent care model on the likelihood that Veterans who are newly diagnosed, metastatic, NSCLC patients will experience the following undesirable health services outcomes: 1) burdensome transitions in the last month of life; 2) "late" (</= 3 days before death) entry into hospice care; 3) receipt of disease modifying chemotherapy or radiation therapy in the last month of life; 4) an ICU stay in their last week of life and death in an ICU; and 5) survival. Based upon which VAMCs manifest higher levels vs. lower levels of concurrent care, we will undertake site visits to those medical centers, interviewing key informants in the oncology, palliative care and nursing services as well as speaking with the local community hospice leadership and other interested parties. Using next of kin surveys in the VA PROMISE database, we will calibrate the quality of life at the end of life assessments in PROMISE with claims based burdensome transitions at the end of life. Finally, using the quality of end of life valuations from the PROMISE data, we will undertake a formal cost-effectiveness analysis of the concurrent care model. If this observational study replicates the published small scale randomized trial, VHA not only has the evidence for more aggressively pursuing concurrent care but the VA is poised to influence national policy on this topic.