Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia

在生命的最后6个月，患有严重疾病的老年人将经常接受侵入性治疗，尽管他们倾向于避免疗效有限的繁重干预措施。例如，不建议患有晚期痴呆症的老年人使用喂食管，但近十分之一的人会接受喂食管。在生命结束时减少过度治疗的策略主要集中在改善沟通上，但系统级的实践模式对患者护理的提供有很大的影响。上游事件和临床规范可以产生一个轨迹的照顾，是很难修改，即使与先进的沟通技巧所采用的姑息治疗专家。 “晚期痴呆老年人护理中临床动力标志物的表征和识别”是一项为期两年的观察性研究，专门响应PA-18-503的探索性或发展性研究提案，以开发专注于老年人群姑息治疗的新工具，方法和模型。我们的研究团队之前已经认识到导致过度治疗的系统级实践模式，并开发了一个概念框架来描述这种现象，我们称之为患有生命限制性疾病的患者的临床动力，例如阿尔茨海默病和其他晚期痴呆症。我们现在需要开发经验工具来识别和测量临床动力，并记录其与这些患者生命末期过度治疗的关系。该提案的目的是描述患有晚期痴呆症的老年人的护理轨迹，这些老年人在急性住院期间放置了饲管，作为临床动力的案例研究。这个2部分的研究旨在评估和扩展我们的概念框架，通过在实践中表征临床势头的组成部分，并确定电子健康记录中的临床势头标记。对于目标1，我们将使用关键的知情人访谈和定性分析来描述事件的轨迹，过程和急性护理的潜在属性，导致喂食管放置晚期痴呆症患者。对于目标2，我们将确定标记物和事件序列，这些标记物和事件序列产生在阿尔茨海默病和其他晚期痴呆患者的医疗记录中明显的临床动力，并通过电子健康记录标识符进行确认。 在完成这项工作后，我们希望能够深入了解导致晚期痴呆症成人喂食管放置的护理轨迹。这项研究是创新的，因为它使用了理论驱动的实证策略，以确定可能发挥关键作用，在提供过度治疗的生活结束的实践模式。这项研究意义重大，因为表征临床动力可以让我们在护理轨迹的早期确定不一致的激励措施和特定时刻，可以采用干预措施来破坏临床动力并提高老年人的护理质量阿尔茨海默病，晚期痴呆症，以及最终其他限制生命的疾病。我们的多学科团队有能力在我们环境中的资源范围内实现我们的目标，使我们能够在2个截然不同的医院环境中研究这个问题。

In the final 6 months of life older adults with serious illness will frequently receive invasive treatments despite preferences to avoid burdensome interventions with limited efficacy. For example, feeding tubes are not recommended for older adults with Advanced Dementia, but nearly one in ten will receive one. Strategies to reduce receipt of overtreatment at the end of life have focused largely on improving communication, yet systems-level practice patterns have a strong influence on the delivery of patient care. Upstream events and clinical norms can produce a trajectory of care that is difficult to modify even with the advanced communication skills employed by palliative care specialists. “Characterization and Identification of Markers of Clinical Momentum in the Care of Older Adults with Advanced Dementia” is a two-year observational study that responds specifically to PA-18-503 for an exploratory or developmental research proposal to develop new tools, methods and models focused on palliative care in geriatric populations. Our research team has previously recognized systems-level practice patterns leading to overtreatment and developed a conceptual framework to describe this phenomenon that we call clinical momentum for patients with life-limiting illness, such as those with Alzheimer’s disease and other advanced dementias. We now need to develop empirical tools to identify and measure clinical momentum and document its relationship to overtreatment at the end of life for these patients. The objective of this proposal is to characterize the trajectory of care for older adults with advanced dementia who have a feeding tube placed during acute hospitalization as a case study of clinical momentum. This 2-part study is designed to evaluate and extend our conceptual framework by characterizing components of clinical momentum in practice and identifying markers of clinical momentum in the electronic health record. For aim 1, we will use key informant interviews and qualitative analysis to describe the trajectory of events, processes, and latent properties of acute care that lead to feeding tube placement for patients with advanced dementia. For aim 2, we will identify markers and the sequence of events generating clinical momentum that are evident in the medical record for patients with Alzheimer’s Disease and other advanced dementias as confirmed by electronic health record identifiers. Upon completion of this work we hope to have a deep understanding of the trajectory of care that leads to feeding tube placement in adults with advanced dementia. This research is innovative because it uses a theory-driven empirical strategy to identify practice patterns that may play a critical role in the provision of overtreatment at the end of life. This research is significant because characterizing clinical momentum could allow us to identify misaligned incentives and specific moments earlier in the trajectory of care where interventions could be employed to disrupt clinical momentum and improve the quality of care for older adults with Alzheimer’s Disease, advanced dementias, and ultimately others with life-limiting illness. Our multidisciplinary team is well positioned to achieve our objectives within the scope of this award given the resources in our environment, allowing us to examine this problem within 2 distinctly different hospital settings.