A Layered Examination of the Patient Experience to Elucidate the Role of Palliative Care in Surgical Care for Seriously Ill Older Adults
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Project Summary . Over 1 million older (≥65 years) adults with serious illness have major surgery or severe trauma each year. After surgery or trauma, older seriously ill patients are at risk for increased healthcare use, functional and cognitive decline, and mortality. National quality guidelines highlight that palliative care focused on aligning treatments with health goals, improving quality of life, alleviating physical and psychological suffering, and addressing social needs, should be provided alongside surgical care at all stages of serious illness. Palliative care for hospitalized seriously ill patients is associated with reduced symptoms and less healthcare utilization after discharge. Although seriously ill surgical patients benefit from palliative care, they are less likely than other hospitalized patients to receive it; this is in part due to research gaps that have inhibited implementation of practical palliative care interventions for older seriously ill surgical patients. Gaps include a dearth of data on patient-oriented surgical outcomes such as pain, depression, and caregiving that can be targeted by palliative care, methodological barriers to measuring palliative care delivery in surgical practice, and little understanding of contextual factors that influence implementation of palliative care in surgery. The proposed study will address these gaps by providing an innovative and layered examination of the role of palliative care in surgery. The study has three specific aims. Aim 1 identifies a cohort of seriously ill older surgical patients (≥66y) using Health and Retirement Study data linked to Medicare claims, and determines the association between direct targets of palliative care (pain, depression, and caregiving needs) and less proximal benefits (reduced healthcare utilization) to demonstrate the important role of palliative care in surgery. Aim 2 identifies a retrospective cohort of older seriously ill surgical patients (≥66y) in a large regional health system and uses Natural Language Processing in electronic health data linked to Medicare Claims to identify palliative care processes (goals of care discussions, healthcare proxy documentation, pain and caregiver assessments) delivered during the surgical episode. The association between palliative care and healthcare utilization in the year after surgical discharge will be tested. Aim 3 uses qualitative interviews and direct observations to obtain an in-depth understanding of contextual factors influencing implementation of palliative care processes in the care of seriously ill older surgical patients (≥65 years). This proposal uses complementary data sources to assess patient-centered outcomes in older seriously ill surgical patients, uses novel methods to evaluate the impact of palliative care processes on outcomes, and deeply examines barriers to implementation of perioperative palliative care in clinical practice. These results will directly inform bedside clinical decisions and the implementation of targeted palliative care interventions to improve care for seriously ill older surgical patients.
