The Impact of physician and health system factors on the quality of care for persons with Alzheimer's disease and related dementias at the end of life

项目摘要 有证据表明，阿尔茨海默病和相关痴呆症(ADRD)患者通常会收到 生命末期的次优护理(EOL)。尽管患者因素(例如，社会经济地位、照顾者 支持)明显影响EOL护理的质量，研究也表明，医生和 卫生系统治疗绝症患者。然而，现有的关于姑息和终生护理质量的研究 主要集中在癌症患者身上，关于EOL护理质量的证据有限 患有ADRD的人。事实上，人们对医生和卫生系统相关因素知之甚少。 为ADRD患者提供姑息性和终生护理的质量。这些知识差距阻碍了 努力制定干预措施，有效提高对ADRD患者的EOL护理质量。 建议的R01将创建一个全面的、多层次的数据库，其中包括以下详细信息 患者、医生和卫生系统，通过链接三个具有全国代表性的大型数据集：(1) Medicare索赔数据(患者因素)，(2)Doximity医生数据库(医生因素)，以及(3)RAND 卫生系统数据库(卫生系统因素)。在目标1中，使用这个创新的数据库，我们将确定 医生因素(例如，年龄、性别、临床经验、专科、住院医师和老年医学研究金培训 和/或姑息治疗)与EOL护理质量相关(定义为：(1)收到预付款 护理计划、姑息治疗和临终关怀，(2)EOL护理的进取性，以及(3)患者结局) 患有ADRD的人。在目标2中，我们将确定卫生系统因素(例如，学术医疗中心、利润 状态、大小、地区、ACO状态)与ADRD患者的EOL护理质量相关。在《目标3》中， 重点关注在多个医疗系统执业的医生(约21%的医生在多个医疗系统执业 卫生系统)，我们将调查卫生系统因素是否影响医生对 对ADRD患者的EOL护理。拟议的R01将提供一个独特的机会，通过以下方式推动该领域的发展 更好地了解医生和卫生系统如何影响EOL护理质量的机制 提供给ADRD患者，特别关注可变的医生因素(例如，教育和培训 在老年病和/或姑息治疗方面)和卫生系统因素(例如，财政激励) EOL护理的质量。该项目将为制定干预措施提供强有力的证据基础(例如， 针对ADRD患者的姑息性和终生护理的医生，对ACOs的财政激励)，这 可以有效地提高在EOL对ADRD患者的护理质量。研究小组由以下人员组成 NIH资助的多名研究人员在所有相关领域都有专业知识(使用大数据的卫生服务研究， 阿尔茨海默病和痴呆症研究、姑息和终生护理研究以及卫生系统研究)，以 进行这项创新性的研究。拟议的研究与NIA的FOA很好地结合在一起，以解决临床和 翻译研究差距，以改善ADRD患者及其家人的高质量EOL护理。

Project Summary Evidence indicates that individuals with Alzheimer's disease and related dementias (ADRD) often receive suboptimal care at the end of life (EOL). Although patient factors (e.g., socioeconomic status, caregiver support) clearly affect the quality of EOL care, studies also demonstrate wide variations in how physicians and health systems treat terminally-ill patients. However, existing studies on the quality of palliative and EOL care have been focused primarily on patients with cancer, and evidence is limited as to the quality of EOL care for persons with ADRD. Indeed, little is known about physician and health system factors that are associated with the quality of palliative and EOL care for persons with ADRD. These knowledge gaps have hindered efforts to develop interventions that can effectively improve the quality of EOL care for persons with ADRD. The proposed R01 will create a comprehensive, multi-level database that includes detailed information about patients, physicians, and health systems, by linking three large, nationally-representative datasets: (1) Medicare claims data (patient factors), (2) Doximity Physician Database (physician factors), and (3) RAND Health System Database (health system factors). In Aim 1, using this innovative database, we will identify physician factors (e.g., age, sex, clinical experience, specialty, residency and fellowship training in geriatrics and/or palliative care) that are associated with the quality of EOL care (defined as (1) the receipt of advance care planning, palliative care, and hospice, (2) aggressiveness of EOL care, and (3) patient outcomes) for persons with ADRD. In Aim 2, we will identify health system factors (e.g., academic medical centers, profit status, size, region, ACO status) associated with the quality of EOL care for persons with ADRD. In Aim 3, focusing on physicians who practice at multiple health systems (about 21% of physicians practice at multiple health systems), we will investigate whether health system factors influence physicians' aggressiveness of EOL care for persons with ADRD. The proposed R01 will provide a unique opportunity to advance the field by better understanding the mechanisms of how physicians and health systems affect the quality of EOL care provided to persons with ADRD, with a special focus on mutable physician factors (e.g., education and training in geriatrics and/or palliative care) and health system factors (e.g., financial incentives) that contribute to the quality of EOL care. This project will provide a strong evidence base for developing interventions (e.g., CME for physicians targeted at palliative and EOL care for persons with ADRD, financial incentives for ACOs), which can effectively improve the quality of care for persons with ADRD at the EOL. The research team consists of multiple NIH-funded researchers with expertise in all relevant fields (health services research using big data, Alzheimer's disease and dementia research, palliative and EOL care research, and health system research) to conduct this innovative research. The proposed study aligns well with the NIA's FOA to address clinical and translational research gaps to improve quality EOL care for people with ADRD and their families.