Health Disparities in Timely Goals of Care Discussions and Hospitalizations Due to Infections in Nursing Home Residents

超过130万居民居住在全国15，600家养老院（NH）。约90% 居民年龄在65岁或以上，超过50%的人处于生命的最后阶段，强调 NHS作为重要的临终关怀机构。此外，NH居民极易感染 每年约有270万人感染，38万多居民死于感染。 事实上，大约50%的NH居民因疑似感染被转移到急性护理医院， 其中高达55%的住院被确定为可能避免的。此外，黑人和西班牙裔 居民更有可能接受次优的姑息治疗，住院率更高， 感染与非西班牙裔和白色居民相比。因此，建议及时 护理目标（TGOC）讨论发生在早期，并在整个护理轨迹中定期进行评估， 临床医生在生命结束时提供目标一致的护理。在感染管理和 临终时的姑息治疗（SIMP-EL; R 01 NR 013687; Stone PI和申办方）研究人员确定了广泛的 关于何时引起居民和/或家庭对护理的偏好，各卫生机构之间存在差异。但没有 有人研究了TGOC讨论如何在NHS中按种族和民族以及其他社会决定因素而变化， 健康包括居民、设施和社区层面的特征。此外，TGOC之间的关系 目前尚不清楚因感染引起的讨论和住院情况。拟议的研究将解决这些差距 通过使用多个数据源对横截面数据集进行二次分析，包括：1）SIMP- 用于TGOC讨论的EL调查; 2）用于NH居民评估的最小数据集3.0; 3）Medicare 医院索赔数据的提供者和分析审查;以及4）其他公开可用的数据源（例如， 美国社区调查）的设施和社区特征。以综合概念为指导， 该框架采用多纳贝迪安和少数群体获得临终关怀模式，具体目标是：（1） 根据居民、设施和社区特征，确定国家卫生机构中TGOC讨论的差异，以及 (2)确定TGOC讨论与因感染住院之间的关联，并检查 居民，设施和社区特征的差异。拟议目标与 国家护理研究所的研究重点是临终关怀和健康差距。以促进 这项研究，申请人将推进她的知识和理解姑息治疗研究有关 长期护理环境中的感染结果，与临终护理过程相关的健康差异，以及 定量研究方法。凭借哥伦比亚的专业指导和资源丰富的环境 大学，申请人将建立一个坚实的基础，从它走向她的长期目标， 成为一名独立的护士科学家，开发研究证据，为卫生政策提供信息， 确保人人享有及时、可及和公平的临终关怀的指导方针。

Over 1.3 million residents live in the 15,600 nursing homes (NHs) across the nation. About 90% of NH residents are 65 years of age or older and more than 50% are in their final stage of life, emphasizing the role of NHs as important end-of-life care settings. In addition, NH residents are highly susceptible to infections with approximately 2.7 million infections occurring every year and more than 380,000 residents dying of infections. Indeed, about 50% of NH residents were transferred to acute care hospitals due to suspected infections, and up to 55% of these hospitalizations were identified as potentially avoidable. Furthermore, Black and Hispanic residents are more likely to receive suboptimal palliative care and have higher rates of hospitalizations due to infections compared to non-Hispanic and White residents. Therefore, it has been recommended that Timely Goals of Care (TGOC) discussions occur early and be evaluated periodically throughout the care trajectory for clinicians to provide goal-concordant care at the end-of-life. In the Study of Infection Management and Palliative Care at End-of-Life (SIMP-EL; R01 NR013687; Stone PI and sponsor) researchers identified wide variations across NHs regarding when residents and/or family preferences for care were elicited. However, no one has examined how TGOC discussions vary in NHs by race and ethnicity, and other social determinants of health including resident, facility, and community level characteristics. Also, the relationships between TGOC discussions and hospitalizations due to infections are not known. The proposed study will address these gaps through a secondary analysis of cross-sectional datasets using multiple data sources including: 1) the SIMP- EL survey for TGOC discussions; 2) the Minimum Data Set 3.0 for NH resident assessments; 3) the Medicare Provider and Analysis Review for hospital claims data; and 4) other publicly available data sources (e.g., American Community Survey) for facility and community characteristics. Guided by an integrated conceptual framework using the Donabedian and Minority Access to End-of-Life Care Models, the specific aims are to: (1) identify differences in the TGOC discussions in NHs by resident, facility, and community characteristics, and (2) determine the association between TGOC discussions and hospitalizations due to infections and examine differences by resident, facility, and community characteristics. The proposed aims are aligned with the National Institute of Nursing Research's research focus on end-of-life care and health disparities. To facilitate this research, the applicant will advance her knowledge and understanding on palliative care research related to infection outcomes in long-term care settings, health disparities related to end-of-life care processes, and quantitative research methods. With the dedicated mentorship and the resource-rich environment of Columbia University, the applicant will build a strong foundation from which to move toward her long-term goal of becoming an independent nurse scientist who develops research evidence that informs health policies and guidelines to ensure timely, accessible, and equitable end-of-life care for all.