Abstract

?PROJECT5 Anadageinacutecaremedicineisthatwhilepatientsdon?twanttodiebadly,theyalsodon?twanttodie. Increasingly,hospital-basedphysiciansmustnegotiatethisdifficultbalance.Theymustimplementtime- sensitivetreatmentalgorithmsforacutecareconditionssuchasseveresepsis,stroke,andheartattackto mitigatemortalityriskwhilesimultaneouslyconsideringpatients?goalsofcaretorespecttheirend-of-life(EOL) treatmentwishes.Makingthisprocessevenmorechallengingisthatoftenthephysicianwillbeseeingthe patientforthefirsttime.Tothisend,hospitalistsoftenhaveadvancecareplanning(ACP)discussionswith patientsandtheirfamilies,oftenregardingadvancedirectives(ADs).Yetratesoftreatment-limitingADs implementedinthehospital(e.g.,?do-not-resuscitate?(DNR)orders)varywidelyfromhospitaltohospitalfor otherwisesimilarseriouslyillolderadults.Similarly,ratesofcardiopulmonaryresuscitation(CPR)and mechanicalventilationamongICUpatientswithpre-existingDNRordersvaryfromICUtoICU,mostlikely reflectingbothover-useandunder-useoftreatments.Thegoalofthisprojectistoimprovethequalityof decisionmakingforseriously-ill,hospitalizedolderadults.Basedonourpriorresearchinvolvingparticipant observation,simulation,andcognitiveinterviewing,ouroverarchinghypothesisisthatasinglephysician judgmentcontributestothesevariations,whetherornotapatientisnearthe?endoflife?(EOL).We hypothesizethatthisjudgmentisnotsimplyaproductofexplicit,knowledge-basedprognostication,butis influencedbyphysicians?heuristics(implicit,unconsciouscognitionrelatedtopatternrecognition)andbylocal socialnorms.
The specificaims ofthisprojectare:1)Tounderstandthecognitiveprocessesthatinfluence hospital-basedphysicians?judgmentthatapatientisnearthe?EOL,?andthereforetheirlikelihoodofACP discussions;?2)ToexploretheassociationbetweenacutecareACPandpatientcareoutcomes;?and3)Totest theeffectofinterventionsdesignedtoinfluencephysiciancognitiveprocesses,comparedtousualcareQI alone,onthelikelihoodofACPdiscussionsusingarandomizedtrial.Toachievetheseaims,wewillusea combinationofobservationalandexperimentalresearchlinkingproprietaryclinicaldatawithclaimsin partnershipwithanationalphysicianmanagementgroup.Thisgrouprepresents2,500hospital-based physiciansat250communityhospitalsacrosstheU.Swhomanageapproximatelyhalfamillionadmissions amongpatients65andoldereachyear.Thisprojectusesresourcesfromall3Cores,providesadata collectionplatformforCoreC?svalidationofnetworkmeasuresemployedbyallprojects,andofferssynergies withProject1and2,includinghowlabelingapatientwithdementiamayinfluencephysicians?decisionsabout acutecaretreatment,ACPdiscussions,andADinterpretation(Project1)andtheassociationbetweenhospital measuresofriskyprescribingandpatientoutcomes(Project2).

  Funding Agency

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Program Projects (P01)
Project #
2P01AG019783-16
Application #
9490979
Study Section
Special Emphasis Panel (ZAG1)
Project Start
2001-09-15
Project End
2023-02-28
Budget Start
2017-12-01
Budget End
2018-11-30
Support Year
16
Fiscal Year
2018
Total Cost
Indirect Cost

  Institution

Name
Dartmouth College
Department
Type
DUNS #
041027822
City
Hanover
State
NH
Country
United States
Zip Code

  Publications

Rosenthal, Meredith B; Colla, Carrie H; Morden, Nancy E et al. (2018) Overuse and insurance plan type in a privately insured population. Am J Manag Care 24:140-146
Bekelis, Kimon; Missios, Symeon; Coy, Shannon et al. (2018) Emergency medical services for acute ischemic stroke: Hub-and-spoke model versus exclusive care in comprehensive centers. J Clin Neurosci :
Chen, Lena M; Ryan, Andrew M; Shih, Terry et al. (2018) Medicare's Acute Care Episode Demonstration: Effects of Bundled Payments on Costs and Quality of Surgical Care. Health Serv Res 53:632-648
Moen, Erika L; Bynum, Julie P; Austin, Andrea M et al. (2018) Assessing Variation in Implantable Cardioverter Defibrillator Therapy Guideline Adherence With Physician and Hospital Patient-sharing Networks. Med Care 56:350-357
Bekelis, Kimon; Missios, Symeon; MacKenzie, Todd A (2018) Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work. Neurosurgery 82:329-334
Jeffery, Molly Moore; Hooten, W Michael; Henk, Henry J et al. (2018) Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study. BMJ 362:k2833
Jeffery, Molly Moore; Hooten, W Michael; Hess, Erik P et al. (2018) Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use. Ann Emerg Med 71:326-336.e19
Finkelstein, Amy; Ji, Yunan; Mahoney, Neale et al. (2018) Mandatory Medicare Bundled Payment Program for Lower Extremity Joint Replacement and Discharge to Institutional Postacute Care: Interim Analysis of the First Year of a 5-Year Randomized Trial. JAMA 320:892-900
Bekelis, Kimon; Missios, Symeon; MacKenzie, Todd A (2018) Correlation of hospital magnet status with the quality of physicians performing neurosurgical procedures in New York State. Br J Neurosurg 32:13-17
Mainor, Alexander J; Morden, Nancy E; Smith, Jeremy et al. (2018) ICD-10 Coding Will Challenge Researchers: Caution and Collaboration may Reduce Measurement Error and Improve Comparability Over Time. Med Care :

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