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。 每年有超过100万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，老年重病患者的医疗保健使用、功能和 认知能力下降和死亡率。国家质量指南强调，姑息治疗的重点是调整 以健康为目标的治疗，改善生活质量，减轻身心痛苦， 在严重疾病的所有阶段，应在提供外科治疗的同时，提供满足社会需求的外科治疗。姑息 对住院重病患者的护理与症状减轻和医疗保健利用减少有关 出院后。虽然重症外科患者受益于姑息治疗，他们不太可能比 其他住院患者接受它;这部分是由于研究差距阻碍了实施 为老年重症外科患者提供切实可行的姑息治疗干预措施。差距包括缺乏数据， 以患者为导向的手术结局，如疼痛、抑郁和疼痛，可以通过姑息治疗进行靶向治疗。 护理，在外科实践中测量姑息治疗提供的方法学障碍，以及对 影响手术姑息治疗实施的环境因素。拟定的研究将 通过对姑息治疗在外科手术中的作用进行创新和分层检查来弥补这些差距。 这项研究有三个具体目标。目的1确定了一个老年外科重症患者（≥ 66岁）队列， 健康和退休研究数据与医疗保险索赔相关联，并确定直接 姑息治疗的目标（疼痛，抑郁和康复需求）和较近的利益（减少 医疗利用），以证明姑息治疗在手术中的重要作用。目标2确定了一个 一个大型区域卫生系统中老年重症外科患者（≥ 66岁）的回顾性队列， 在与医疗保险索赔相关的电子健康数据中进行自然语言处理，以识别姑息治疗 过程（护理讨论的目标、医疗保健代理文件、疼痛和护理人员评估） 在手术过程中输送的姑息治疗和医疗保健利用之间的关联 手术后一年出院将进行测试。目标3使用定性访谈和直接观察来获得 深入了解影响姑息治疗过程实施的背景因素， 老年外科重症患者（≥65岁）的护理。该提案使用补充数据源， 评估以患者为中心的结果，在老年重病手术患者，使用新的方法来评估 姑息治疗过程对结果的影响，并深入探讨了实施 围手术期姑息治疗的临床实践。这些结果将直接为床边临床决策提供信息， 实施有针对性的姑息治疗干预措施，以改善重症老年外科手术患者的护理 患者

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.