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

摘要：与非拉丁裔白人相比，拉丁裔人接受的临终关怀（例如，ICU停留，复苏）更具侵略性，负担更重，临终关怀更少。现有的证据表明，拉丁美洲人接受的终末期护理可能是次优的，与他们的愿望不一致，不如白人接受的终末期护理。 本研究的总体目标是确定最有希望的干预目标，旨在使拉丁美洲人获得：a）高质量的EOL护理，和B）护理符合他们的价值观和偏好（“治疗目标的实现”）。我们和其他人的初步结果表明，机构、提供者和患者层面的数据至关重要，这样就可以看出他们的相对影响力。主 该研究的目的是获得多层次数据，并使用分层线性模型（HLM）来估计患者，提供者和机构对拉丁裔白人在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的首要地位超过机构的影响，这将是显着的，但影响力小于患者或提供者的影响。我们将从美国的5个研究中心招募250例预期寿命不到6个月的晚期胃肠道和胸部癌症患者（125例拉丁裔，125例非拉丁裔白色）。我们还将招募50名肿瘤学提供者，每人至少护理5名研究受试者 将通过尸检评估中的病历提取记录患者在生命最后一个月接受的医疗护理。我们预计，这项研究将告知政策制定者和机构领导，他们应该在哪里投资最大的“爆炸的钱”，以减少拉丁裔白人在EOL护理的差距。 该研究小组由EOL护理领域的领先专家冬青Prigerson博士和对差异感兴趣的全国公认的老年病学家Jan Mutchler博士组成，他们准备与DFCI（Jimenez）的一名初级研究员和一名希望提高研究技能和专业知识的UMB副教授（里维拉）合作开展这项工作。该项目将大大受益于培训、调查和统计方法核心提供的支持。

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.