My career goal is to become an independent investigator whose work improves conversations between clinicians and older patients with advanced heart failure (HF) and their caregivers. This application proposes 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 my research training and experience through mentored research, formal coursework and self-directed learning activities and develop independence through leadership and networking opportunities. The work proposed in this application involves studying goals of care discussions (GOCD) in older adults with advanced HF. As one of the leading causes of death, hospitalization, readmission and Medicare costs, HF is associated with poor health-related quality of life, significant psychological distress and increased health care spending for patients and their caregivers. The complex and changing trajectory of advanced HF along with the available life-sustaining therapies makes decision-making more complex in older adults as compared to other serious illnesses. Recent data in advanced cancer patients demonstrate that GOCD result in improved patient and caregiver outcomes. Unlike cancer, HF patients have highly variable prognoses, invasive potential treatments associated with major lifestyle changes, and unpredictable symptom crises, which make it difficult to extrapolate findings from cancer to HF. This proposal aims to address this gap. We hypothesize that improved GOCD will result in improved patient outcomes (receipt of treatments aligned with preferences, better quality of life, less depression and anxiety and decreased utilization) and caregiver outcomes (less depression, anxiety and caregiver burden, and improved satisfaction) as compared to patients who do not have GOCD.
The aims of these projects are: (SA1) to identify barriers and facilitators to GOCD in older adults with advanced HF and to identify patient and caregiver health-related outcomes associated with GOCD; (SA2) to develop and refine HF Connect, a HF- specific GOCD training module, to meet the unique needs of these patients and caregivers; and (SA3) to conduct a pilot RCT of PREPARE + HF Connect to determine feasibility of enrollment, efficacy to increase GOCD and advanced care planning behaviors, and satisfaction with the tailored module. To achieve the first aim, I will analyze a multicenter cohort of advanced HF patients and their caregivers to identify the factors that predict GOCD and outcomes of these conversations. Next, I will interview patient/caregiver dyads to identify barriers and facilitatorsof GOCDs. Using SA1 data, I will develop HF Connect and use cognitive interviews with patients, caregivers and clinicians to refine it (SA 2). Finally, I will conduct a small RCT of HF Connect (SA3) to determine its feasibility and efficacy. These studies will generate data that will allow m to secure R01-level funding to test HF Connect in a multicenter RCT. The proposed research and career development plan are initial steps toward improving the care of older adults with advanced HF and their caregivers.

Public Health Relevance

Public Health Relevance: Because heart failure is a disease of older adults, with more Medicare dollars spent on the diagnosis and treatment of heart failure than any other diagnosis, it is critical to gain an understanding of how goals of care discussions can be directed to improve care for this population and its caregivers. By understanding the determinants, barriers and facilitators of goals of care discussions in this population, we can design a tailored intervention to target effectively the needs of older adults with advanced heart failure and their caregivers; there has the potential implications for improving quality of care an minimizing cost of care for this population.

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Mentored Patient-Oriented Research Career Development Award (K23)
Project #
5K23AG049930-02
Application #
9269956
Study Section
Clinical Aging Review Committee (NIA-C)
Program Officer
Gerald, Melissa S
Project Start
2016-05-15
Project End
2021-04-30
Budget Start
2017-05-15
Budget End
2018-04-30
Support Year
2
Fiscal Year
2017
Total Cost
$129,637
Indirect Cost
$9,227
Name
Icahn School of Medicine at Mount Sinai
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
078861598
City
New York
State
NY
Country
United States
Zip Code
10029
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Brown, Elizabeth; Morrison, R Sean; Gelfman, Laura P (2018) An Update: NIH Research Funding for Palliative Medicine, 2011-2015. J Palliat Med 21:182-187
Gelfman, Laura P; Bakitas, Marie; Warner Stevenson, Lynne et al. (2017) The State of the Science on Integrating Palliative Care in Heart Failure. J Palliat Med 20:592-603
Taylor, Richard A; Smith, Cardinale B; Coats, Heather et al. (2017) Update in Hospice and Palliative Care. J Palliat Med 20:1189-1194
Kavalieratos, Dio; Gelfman, Laura P; Tycon, Laura E et al. (2017) Palliative Care in Heart Failure: Rationale, Evidence, and Future Priorities. J Am Coll Cardiol 70:1919-1930
Yim, Cindi K; Barrón, Yolanda; Moore, Stanley et al. (2017) Hospice Enrollment in Patients With Advanced Heart Failure Decreases Acute Medical Service Utilization. Circ Heart Fail 10:
Xie, Kira; Gelfman, Laura; Horton, Jay R et al. (2017) State of Research on Palliative Care in Heart Failure as Evidenced by Published Literature, Conference Proceedings, and NIH Funding. J Card Fail 23:197-200
Gelfman, Laura P; Kavalieratos, Dio; Teuteberg, Winifred G et al. (2017) Primary palliative care for heart failure: what is it? How do we implement it? Heart Fail Rev 22:611-620
Weerahandi, Himali; Goldstein, Nathan; Gelfman, Laura P et al. (2016) Pain and Functional Status in Patients With Ventricular Assist Devices. J Pain Symptom Manage 52:483-490.e1
Ouchi, Kei; Knabben, Vinicius; Rivera-Reyes, Laura et al. (2016) Preparing Older Adults with Serious Illness to Formulate Their Goals for Medical Care in the Emergency Department. J Palliat Med :