Impact of POLST Adoption and of Financial Incentives on Care Receipt and on Intensity of Care Preferences in Nursing Home Patients

摘要 繁重的过渡-在生命结束时增加护理强度（EOL）-不一定是期望的， 病人或他们的律师。阿尔茨海默病及其相关痴呆（AD/ADRD）患者经常 要求他们的代理人（无论是家庭还是其他决策者）确保他们的愿望得到满足。 met.先前的工作表明，存在一个先进的指令或其他形式的先进的护理计划， 与国家疗养院（NH）人群中EOL时较低的繁重过渡率相关。使用 POLST与终末期痴呆患者中ICU使用率较低相关。NH质量-作为 由CMS在NH Compare中的五颗星星评级衡量-与POLST的更高完成度相关 在长期NH患者中，大多数人筛查出明显的认知障碍。 AD/ADRD患者代表了一个具有挑战性但适合POLST实施的人群， 减少生命末期的过渡负担。POLST的目标是将患者的愿望编入一个单一的 记录医生对护理强度的具体医嘱的文档。我们的目标是让医疗服务提供者 遵守命令AD/ADRD患者高度依赖他人完成和维持POLST 这反映了他们的愿望。 在初步工作中，我们已经表明，NH质量与POLST完成。不太清楚，如果 质量影响AD/ADRD患者在NH内完成POLST的方式。做低质量的NH 反映患者意愿和/或其代理人的最佳判断的完整POLST？或者，质量较低 当POLST完成时，NH默认接受更高强度的治疗，导致AD/ADRD患者 经历更繁重的过渡，在生命结束时接受更高强度的护理？ 在这份行政补充报告中，我们将调查NH质量对护理偏好和护理的影响。 在加州，对患有AD/ADRD且在生命终了时有显著认知障碍的个体进行分娩（2011年至 2018年），以具体解决以下具体目标： 1.确定NH质量的总体和组成特征对POLST完成的影响， LTC AD/ADRD患者在生命末期的患者偏好。 2.确定NH质量对LTC患者在生命终了时的繁重过渡的影响 AD/ADRD在寿命结束时说明POLST完成。 本补充文件将特别说明NH质量如何影响患者的完成和记录 一种类型的ACP工具-POLST -的偏好，以及NH质量和POLST如何相互作用， 影响AD/ADRD患者EOL时护理强化。

ABSTRACT Burdensome transitions – increases in intensity of care at the end of life (EOL) – are not necessarily desired by patients or their advocates. Patients with Alzheimer’s disease and its related Dementias (AD/ADRD) frequently require the agency of their proxies (whether family or other decision makers) to ensure that their wishes are met. Prior work has shown that existence of an advanced directive or other forms of advanced care planning is associated with lower rates of burdensome transitions at EOL in a national nursing home (NH) population. Use of POLST has been associated with lower ICU use among patients with dementia at EOL. NH quality – as measured by the CMS Five Star Rating in NH Compare – is associated with greater completion of POLST among long term NH patients, most of who screen for significant cognitive impairment. Patients with AD/ADRD represent a challenging, but appropriate population for POLST implementation to reduce burdensome transitions at the end of life. The goal of POLST is to codify patient’s wishes in a single document that captures the physician’s specific orders for care intensity. The goal is for medical providers to follow these orders. Patients with AD/ADRD are highly dependent on others to complete and maintain POLSTs that reflect their wishes. In preliminary work, we have shown that NH quality is associated with POLST completion. It is less clear if NH quality impacts how POLST is completed within NH among patients with AD/ADRD. Do lower quality NHs complete POLSTs that reflect patient wishes and / or the best judgement of their proxies? Or, are lower quality NHs defaulting to higher intensity care when POLSTs are completed, resulting in patients with AD/ADRD undergoing more burdensome transitions and receiving higher intensity care at the end of life? In this administrative supplement, we will investigate the impact of NH quality on care preferences and care delivery for individuals with AD/ADRD with significant cognitive impairment at the end life in California (2011 to 2018) in order to specifically address the following specific aims: 1. Determine the impact of overall and constituent characteristics of NH quality on POLST completion and patient preferences among LTC patients with AD/ADRD at the end-of-life. 2. Determine the impact of NH quality on burdensome transitions at the end-of-life among LTC patients with AD/ADRD at the end-of-life accounting for POLST completion. This supplement will specifically address how NH quality influences the completion and recording of patient preferences in one type of ACP instrument – the POLST – and how NH quality and POLST interact to influence intensification of care at EOL for patients with AD/ADRD.