This proposal represents a five-year curriculum and research plan designed to facilitate my development to an independent investigator in patient-oriented aging research. During the five years of the award, I will expand on my health services research training and experience through mentored research, formal coursework, and selfdirected learning activities and develop independence through leadership and networking opportunities. The current pace of U.S. healthcare spending is unsustainable as the oldest segments of the population expand. Hospital services account for the largest portion of Medicare costs, the bulk of which goes to a specific patient population: older adults with serious illness. Geographic regions vary widely in their intensity of hospital use and some argue this represents discretionary or unnecessary hospital-based care. Increased spending is also not associated with higher quality, as measured by longevity, quality of life, and satisfaction. Understanding what factors contribute to unnecessary hospitalizations among at-risk older adults is essential for development of successful new models of efficient, patient-centered care. Thus, the goal of my research is to prospectively identify seriously ill older adults at risk of hih-cost hospital-based care, and identify "triggers" of potentially avoidable hospitalizations and barriers to remaining in the community for these patients. Specifically, I plan to: (SA1) Build upon my prior work by examining determinants of hospital expenditures, number of hospital admissions and high-intensity, hospital-based treatment in the last year of life among the Health and Retirement Study (HRS) cohort using a mortality follow-back design;(SA2) Expand my earlier findings by evaluating factors associated with hospital expenditures, number of hospitalizations and treatment intensity among a cohort of seriously ill older adults matched prospectively by 1-year mortality risk;and (SA3) Support the development of an intervention to reduce unnecessary hospital admissions among at-risk older adults by investigating reasons for multiple hospital admissions and barriers to management outside the hospital among seriously ill older adults by conducting qualitative interviews with patients, caregivers and primary care physicians. The proposed work uses an innovative combination of regional, patient-level and claims data to evaluate factors driving treatment intensity in this population;examines outcomes with both a traditional mortality follow-back study design and a novel prospective analytic technique;and employs mixed methods to learn from patients and families what problems lead to excess hospitalizations and how those challenges might be overcome. Through my current work and future independent research, I plan to create a patient-centered intervention to reduce unnecessary hospitalizations among seriously ill older adults and translate my work to effective health care policies and clinical programs. The proposed research and career development plan are important initial steps toward advancing the care of older adults by improving medical decision making in the face of serious illness and promoting policies that better align treatments with patient preferences.

Public Health Relevance

This research will use innovative methods to prospectively examine factors contributing to unnecessary hospital admissions among at-risk older adults. A critical first step toward reducing unnecessary high-cost hospital-based care, this research will contribute knowledge needed to develop successful new models of efficient, high-quality, preference-driven care for older adults with serious illness and promote health care policies that better align treatments with patient preferences.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Mentored Patient-Oriented Research Career Development Award (K23)
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Special Emphasis Panel (ZAG1-ZIJ-6 (M1))
Program Officer
Baker, Colin S
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Icahn School of Medicine at Mount Sinai
Internal Medicine/Medicine
Schools of Medicine
New York
United States
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Ramaswamy, Ravishankar; Williams, Alicia; Clark, Elizabeth M et al. (2014) Communication skills curriculum for foreign medical graduates in an internal medicine residency program. J Am Geriatr Soc 62:2153-8
Tschirhart, Evan C; Du, Qingling; Kelley, Amy S (2014) Factors influencing the use of intensive procedures at the end of life. J Am Geriatr Soc 62:2088-94
Kelley, Amy S; Langa, Kenneth M; Smith, Alexander K et al. (2014) Leveraging the health and retirement study to advance palliative care research. J Palliat Med 17:506-11
Berger, Arielle S; Dunn, Andrew S; Kelley, Amy S (2014) A standardized bleeding risk score aligns anticoagulation choices with current evidence. Crit Pathw Cardiol 13:109-13
Reckrey, Jennifer M; Decherrie, Linda V; Kelley, Amy S et al. (2013) Health care utilization among homebound elders: does caregiver burden play a role? J Aging Health 25:1036-49
Kelley, Amy S (2013) Epidemiology of care for patients with serious illness. J Palliat Med 16:730-3
Kelley, Amy S; Deb, Partha; Du, Qingling et al. (2013) Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Aff (Millwood) 32:552-61