The Impact of Hospice Preferred Practices on Patient Outcomes and Hospice Costs

描述（由申请人提供）：最近，国家质量论坛（NQF）认可了一套缓和和临终关怀质量的首选实践，并将临终关怀服务确定为医疗保健质量改进的国家优先领域。然而，首选做法主要是通过专家意见确定的，并且没有全国性的研究将安宁疗护首选做法的使用与患者结果和安宁疗护成本联系起来。该领域继续取得进展的一个关键障碍是建立NQF首选做法的证据基础，正如本提案所寻求的那样。本纵向研究的具体目的是：1)确定安宁疗护首选做法（例如，24小时危机管理电话访问，更频繁的疼痛和症状管理做法）与接受安宁疗护患者的医院利用（包括重症监护室和急诊科入院）以及医院与家庭死亡之间的关系；2)确定安宁疗护首选实务（例如，伦理委员会、包括护士、社工、医生和牧师在内的跨学科团队会议、更频繁的疼痛和症状管理实务）与安宁疗护退订及安宁疗护住院时间之间的关联；以及3)检视安宁疗护偏好实务对安宁疗护成本的影响。到目前为止，这样的研究是不可行的，因为我们缺乏关于临终关怀医院使用首选做法的国家数据；然而，卡尔森博士最近的工作是通过她的国家护理研究所K99/R00收集并检查了国家临终关怀调查的数据，该调查调查了一个国家随机抽样的临终关怀医院（N=591, 84%的回复率），关于他们使用以患者为中心和以家庭为中心的NQF首选实践。这项提案的目的将通过将全国临终关怀调查数据与临终关怀医院在调查完成日期后新登记的患者的医疗保险索赔数据以及临终关怀费用报告联系起来来实现。我们将采用层次广义线性模型来检验安宁疗护偏好做法与结果之间的关联，并考虑病人、安宁疗护机构和县层面的协变量。拟议的项目在使用关于临终关怀医院使用首选做法的第一个详细的国家数据并将这些数据与患者结果和临终关怀成本联系起来方面具有创新性。卡尔森博士组建的多学科研究团队具有成功完成该项目的背景和专业知识。本研究的贡献将是显著的，因为它将确定与患者预后和安宁疗护成本最密切相关的具体安宁疗护实践。这些信息可以指导关于最佳做法的国家建议，并将为监管和专业干预提供信息，以监测和促进更高质量、更具成本效益的临终护理

DESCRIPTION (provided by applicant): Recently, the National Quality Forum (NQF) endorsed a set of preferred practices for palliative and hospice care quality and identified hospice services as a national priority area for healthcare quality improvement. The preferred practices, however, were primarily identified through expert opinion and there have been no national studies linking use of hospice preferred practices with patient outcomes and hospice costs. A critical barrier to continued progress in the field is building the evidence base for the NQF preferred practices, as this proposal seeks to do. The Specific Aims of this longitudinal study are: 1) Determine the association between hospice preferred practices (e.g., 24-hour crisis management phone access, more frequent pain and symptom management practices) and hospital utilization by patients receiving hospice care, including intensive care unit and emergency department admissions, and hospital versus home death; 2) Determine the association between hospice preferred practices (e.g., an ethics committee, interdisciplinary team meetings that include nurses, social workers, physicians and chaplains, more frequent pain and symptom management practices) and hospice disenrollment and hospice length of stay; and 3) Examine the impact of hospice preferred practices on hospice costs. Until now, such a study was not feasible because we lacked national data on the use of preferred practices by hospices; however, Dr. Carlson's recent work conducted through her National Institute of Nursing Research K99/R00 collected and examined data from the National Hospice Survey, which surveyed a national random sample of hospices (N=591, 84% response rate) regarding their use of patient-centered and family- centered NQF preferred practices. The aims of this proposal will be accomplished by linking the National Hospice Survey data to Medicare claims data for patients newly enrolled by hospices following the survey completion date and to hospice costs reports. We will employ hierarchical generalized linear models to test the associations between hospice preferred practices and outcomes, accounting for patient, hospice, and county level covariates. The proposed project is innovative in using the first, detailed national data on the use of preferred practices by hospices and linking these data to patient outcomes and hospice costs. The multidisciplinary research team assembled by Dr. Carlson has the background and expertise to successfully complete this project. The contribution of this study will be significant because it will identify the specific hospice practies that most strongly relate to patient outcomes and hospice costs. Such information may guide national recommendations on best practices and will inform regulatory and professional interventions to monitor and promote higher quality, more cost effective care at the end of life in the hospice setting.