Leveraging a Natural Experiment to Determine the Effects of Integrated Palliative Care on Health Service Outcomes and Disparities in Parkinson Disease and Lewy Body Dementia

项目总结/摘要 在目前的护理模式下，患有帕金森病（PD）或帕金森病痴呆症的人 (PDD)，接受过度的、低价值的护理。PD和PDD中的“非运动”症状认识不足， 治疗不足，是住院和机构化的主要诱因。潜在 在PD和PDD中，非运动症状的不适当药物使用是普遍的。高级护理计划 罕见（<5%），临终时的ICU护理和院内死亡很常见（>20%）。解决这些未解决的问题 需求，属于护理计划，症状管理，安全处方， 和临终关怀将对人口健康产生重大影响。 患有PD和PDD的人也得到不平等的照顾。早期的研究表明， 个体因素--女性、西班牙裔、亚裔和黑人--与较低的 接受指导性PD和PDD治疗。反过来，目前减少差距的战略侧重于个人 行为（如寻求帮助），即使差异也是由提供者的因素驱动的， 卫生系统和政策层面。扩大PD/PDD差异研究的范围，以包括以下研究： 卫生保健组织结构和护理提供过程可以确定新的机制途径， 这是一个新的挑战，也为实现公平的结果开辟了新的途径。 疾病定制姑息治疗（PC）已被证明可以改善结果并减少低价值护理 在多种神经系统疾病中。最近，PD定制的，基于团队的，神经病学主导的PC已经被 经证实，可改善患者的生活质量、非运动症状管理和护理人员的结局。 基于这些结果，一个大规模的实施项目，使综合PC的新的护理标准， 大约一半的美国学术运动障碍中心正在进行中。我们建议利用 由实施项目创建的自然实验，以确定神经病学团队领导的PC对 卫生服务成果，并提供证据的程度，改变卫生保健 组织结构和交付过程影响医疗保健和结果差异， 少数民族、女性、农村和社会经济上处于不利地位的PD和PDD人群。 本申请的目的是（1）检查PC领域的医疗保健使用和PC之间的差异 患有PD和PDD的Medicare受益人，以及（2）测试PC干预对PC域健康的影响 护理利用结果和结果差异。我们建议的工作将产生基准国家数据， PD，PDD结果，阐明PD和PDD差异的中心水平变化。我们还希望通知 PD/PDD特异性神经姑息治疗标准。我们的研究结果将影响神经学研究和护理， 我们通过公共卫生和卫生公平评估正在进行的传播项目的创新方法 透镜，以了解学术神经病学中心差异的驱动因素。

PROJECT SUMMARY/ABSTRACT Under current care models, persons living with Parkinson Disease (PD) or Parkinson Disease Dementia (PDD), receive excessive, low-value care. “Non-motor” symptoms in PD and PDD are underrecognized and undertreated and are the leading precipitants of hospitalization and institutionalization. Potentially inappropriate medication use for non-motor symptoms is widespread in PD and PDD. Advanced care planning is rare (<5%), ICU care at the end of life and in-hospital deaths are common (>20%). Addressing these unmet needs, which fall under the palliative care domains of care planning, symptom management, safe prescribing, and end of life care would have major population health impacts. Persons living with PD and with PDD also receive unequal care. Early work has shown that static individual factors-female sex, Hispanic ethnicity, and Asian and Black race- associate with a lower likelihood of receiving guideline PD and PDD care. In turn, current strategies to reduce disparities focus on individual behaviors (like help-seeking), even though disparities are also driven by factors operating at the provider, health system and policy levels. Broadening the scope of PD/PDD disparities research to include the study of health care organizational structure and care delivery processes could identify new mechanistic pathways for such disparities, and open new avenues for achieving equitable outcomes. Disease-tailored palliative care (PC) has been shown to improve outcomes and reduces low-value care in multiple neurological diseases. Recently, PD-tailored, team-based, neurology-led PC has been demonstrated to improve patient quality of life, non-motor symptom management and caregiver outcomes. Based on these results, a large-scale implementation project to make integrated PC the new care standard in approximately half of U.S. academic Movement Disorders Centers is underway. We propose to leverage the natural experiment created by the implementation project to determine the effects of neurology team led PC on health service outcomes, and to provide evidence on the degree to which alterations of health care organizational structure and delivery processes impact health care and outcome disparities experienced by minority,female, rural, and socioeconomically disadvantaged PD and PDD populations. The aims of this application are (1) to examine PC domain health care use and PC disparities among Medicare beneficiaries with PD and PDD, and (2) to test the effects of a PC Intervention on PC domain health care utilization outcomes and outcome disparities. Our proposed work will produce benchmark national data on PD, PDD outcomes, illuminate center-level variations in PD and PDD disparities. We also expect to inform PD/PDD-specific neuropalliative care standards. Our results will impact neurology research and care through our innovative approach of evaluating an ongoing dissemination project through public health and health equity lenses to understand the drivers of academic neurology center disparities.