Latino End-of-Life Care: Patient, Provider, & Institutional Effects

摘要：与非拉美裔白人相比，拉美裔美国人得到的临终关怀更具攻击性、负担更重(例如，留在ICU、复苏)，而临终关怀较少。现有证据表明，拉美裔人获得的EOL护理可能不是最理想的，与他们的意愿不一致，而且不如白人获得的EOL护理。 这项研究的总体目标是确定最有希望的干预目标，旨在使拉美裔人能够获得：a)高质量的终生保健，以及b)与他们的价值观和偏好一致的护理(“达到治疗目标”)。我们和其他人的初步结果表明，在机构、提供者和患者层面上迫切需要数据，以便能够识别它们的相对影响。初级阶段 这项研究的目的是获得多水平的数据，并使用分层线性建模(HLM)来估计患者、提供者和机构对拉美裔白人在EOL护理和治疗目标实现方面的差异的影响。 我们假设患者和提供者优先于制度效应，这将是重要的，但比病人或提供者的影响要小。我们将从全美五个地点招募250名预期寿命小于6个月的晚期胃肠道和胸癌患者(125名拉丁裔，125名非拉丁裔白人)。我们还将招募总共50名肿瘤学提供者，他们每人至少照顾5名研究参与者 患者在生命的最后一个月接受的医疗护理将通过尸检评估中的医疗图表提取来记录。我们预计，这项研究将告诉政策制定者和机构领导层，他们应该在哪里投资，以最大限度地“物有所值”，以减少拉美裔白人在EOL护理方面的差异。 研究团队由EOL护理领域的领先专家Holly Prigerson博士和对差异有着浓厚兴趣的全国公认的老年学家Jan Mutchler博士组成，准备与DFCI(Jimenez)的一名初级研究员和UMB希望提高她的研究技能和专业知识的一名副教授(Rivera)合作开展这项工作。该项目将大大受益于培训和调查及统计方法核心提供的支助。

Abstract: Latinos receive more aggressive, burdensome end-of-life (EOL) care (eg, ICU stays, resuscitation) and less hospice care than non-Latino whites. The available evidence suggests that the EOL care Latinos receive may be suboptimal and inconsistent with their wishes, and inferior to the EOL care that whites receive. The overarching aim of this study is to identify the most promising targets for interventions designed to enable Latinos to receive: a) high quality EOL care, and b) care consistent with their values and preferences ("treatment goal attainment"). Our preliminary results, and those of others, suggest that there is a critical need for data at institutional, provider, and patient levels so that their relative influence can be discerned. The primary aims ofthe proposed study are to obtain multi-level data and use hierarchical linear modeling (HLM) to estimate patient, provider and institutional effects on Latino-white disparities in EOL care and treatment goal attainment. We hypothesize the primacy of patient and provider over institution effects, which will be significant, but less influential than either patient or provider effects. We will recruit 250 advanced gastrointestinal and thoracic cancer patients (125 Latino, 125 non-Latino white) with a life-expectancy of less than 6 months from five sites across the US. We will also enroll 50 oncology providers overall who each care for at least 5 study participants The patient's medical care received in the last month of life will be documented via medical chart extraction in the postmortem assessment. We anticipate that this study will inform policy makers and institutional leadership of where they should invest for the greatest "bang for the buck" to reduce Latino-white disparities in EOL care. The study team, comprised of Dr. Holly Prigerson, a leading expert in EOL care, and Dr. Jan Mutchler, a nationally recognized gerontologist with strong interests in disparities, is well-poised to undertake this work, in collaboration with a junior investigator at DFCI (Jimenez) and a UMB Associate Professor who wants to increase her research skills and expertise (Rivera). This project will benefit significantiy from support provided by the Training and Survey and Statistical Methods Cores.