The Impact of Hospice Preferred Practices on Patient Outcomes and Hospice Costs

描述(由申请者提供)：最近，国家质量论坛(NQF)批准了一套姑息和临终关怀质量的首选实践，并将临终关怀服务确定为国家优先改善医疗质量的领域。然而，首选做法主要是通过专家意见确定的，还没有全国性的研究将临终关怀首选做法的使用与患者结果和临终关怀成本联系起来。在这一领域继续取得进展的一个关键障碍是为NQF首选做法建立证据基础，正如本提案试图做到的那样。这项纵向研究的具体目标是：1)确定临终关怀首选做法(例如，24小时危机管理电话接入、更频繁的疼痛和症状管理做法)与接受临终关怀的患者对医院的利用之间的关联，包括重症监护病房和急诊科入院，以及医院与家庭死亡；2)确定临终关怀首选做法(例如，道德委员会、包括护士、社会工作者、医生和牧师在内的跨学科团队会议、更频繁的疼痛和症状管理做法)与临终关怀取消登记和临终关怀住院时间之间的关联；以及3)研究临终关怀首选做法对临终关怀成本的影响。到目前为止，这样的研究是不可行的，因为我们缺乏关于临终关怀机构使用首选实践的全国性数据；然而，Carlson博士最近通过她的国家护理研究所K99/R00进行的工作收集并检查了来自全国临终关怀调查的数据，该调查调查了全国临终关怀机构(N=591，84%的应答率)使用以患者为中心和以家庭为中心的NQF首选实践的情况。这项提案的目的将通过将全国临终关怀调查数据与调查完成日期后临终关怀机构新登记的患者的联邦医疗保险索赔数据以及临终关怀成本报告联系起来。我们将使用分层的广义线性模型来测试临终关怀首选实践和结果之间的关联，考虑到患者、临终关怀和县级协变量。拟议的项目在使用第一个关于临终关怀机构使用首选做法的详细国家数据并将这些数据与患者结果和临终关怀费用联系起来方面具有创新性。由卡尔森博士组建的多学科研究团队拥有成功完成这一项目的背景和专业知识。这项研究的贡献将是重大的，因为它将确定与患者结局和临终关怀成本最密切相关的具体临终关怀实践。这些信息可指导关于最佳做法的国家建议，并将为监管和专业干预提供信息，以监测和促进在#年生命末期提供更高质量、更具成本效益的护理 临终关怀的环境。

DESCRIPTION (provided by applicant): Recently, the National Quality Forum (NQF) endorsed a set of preferred practices for palliative and hospice care quality and identified hospice services as a national priority area for healthcare quality improvement. The preferred practices, however, were primarily identified through expert opinion and there have been no national studies linking use of hospice preferred practices with patient outcomes and hospice costs. A critical barrier to continued progress in the field is building the evidence base for the NQF preferred practices, as this proposal seeks to do. The Specific Aims of this longitudinal study are: 1) Determine the association between hospice preferred practices (e.g., 24-hour crisis management phone access, more frequent pain and symptom management practices) and hospital utilization by patients receiving hospice care, including intensive care unit and emergency department admissions, and hospital versus home death; 2) Determine the association between hospice preferred practices (e.g., an ethics committee, interdisciplinary team meetings that include nurses, social workers, physicians and chaplains, more frequent pain and symptom management practices) and hospice disenrollment and hospice length of stay; and 3) Examine the impact of hospice preferred practices on hospice costs. Until now, such a study was not feasible because we lacked national data on the use of preferred practices by hospices; however, Dr. Carlson's recent work conducted through her National Institute of Nursing Research K99/R00 collected and examined data from the National Hospice Survey, which surveyed a national random sample of hospices (N=591, 84% response rate) regarding their use of patient-centered and family- centered NQF preferred practices. The aims of this proposal will be accomplished by linking the National Hospice Survey data to Medicare claims data for patients newly enrolled by hospices following the survey completion date and to hospice costs reports. We will employ hierarchical generalized linear models to test the associations between hospice preferred practices and outcomes, accounting for patient, hospice, and county level covariates. The proposed project is innovative in using the first, detailed national data on the use of preferred practices by hospices and linking these data to patient outcomes and hospice costs. The multidisciplinary research team assembled by Dr. Carlson has the background and expertise to successfully complete this project. The contribution of this study will be significant because it will identify the specific hospice practies that most strongly relate to patient outcomes and hospice costs. Such information may guide national recommendations on best practices and will inform regulatory and professional interventions to monitor and promote higher quality, more cost effective care at the end of life in the hospice setting.