定量研究记录了持续的区域性,设施,以及向患有晚期痴呆症的疗养院(NH)居民提供的护理强度的种族差异,美国东南部的强度更大,在黑人居民中,同一医院转诊地区(HRR)的NHs之间差异很大。人们对这些差异的原因知之甚少,研究它们的适当方法描述得很糟糕。
评估阿尔茨海默病的差异和变异在生命结束时的疗养院护理(ADVANCE)是一项大型的定性研究,旨在阐明与NH组织文化和代理人观点相关的因素,这些因素导致了晚期痴呆护理强度的差异。使用全国2016-2017年最小数据集信息,根据有这种情况的居民的医院转院率和管饲率,确定了4个HRR,其中晚期痴呆护理的相对强度高(N=2个HRR)和低(N=2个HRR).在这些HRs中,我们确定了在该HRR中相对于所有NHs提供高(N=2NHs)和低(N=2NHs)强度护理的设施(总共N=16个设施;4个设施/HRR).
到目前为止,研究小组在13个NHs中进行了275小时的观察,并采访了158个来自不同学科的NH提供者,以评估物理环境,护理过程,决策过程,和价值观。我们采访了44名代理人(黑人,N=19;白色,N=25)关于他们对预先护理计划的看法,决策,值,通信,支持,信任,识字,关于死亡的信念,和灵性。本报告描述了ADVANCE研究设计及其实施的促进者和挑战,为专注于NHs优质护理的大型定性研究的成功应用提供模板。
Quantitative studies have documented persistent regional, facility, and racial differences in the intensity of care provided to nursing home (NH) residents with advanced dementia including, greater intensity in the Southeastern United States, among black residents, and wide variation among NHs in the same hospital referral region (HRR). The reasons for these differences are poorly understood, and the appropriate way to
study them is poorly described.
Assessment of Disparities and Variation for Alzheimer\'s disease Nursing home Care at End of life (ADVANCE) is a large qualitative
study to elucidate factors related to NH organizational culture and proxy perspectives contributing to differences in the intensity of advanced dementia care. Using nationwide 2016-2017 Minimum DataSet information, four HRRs were identified in which the relative intensity of advanced dementia care was high (N = 2 HRRs) and low (N = 2 HRRs) based on hospital transfer and tube-feeding rates among residents with this condition. Within those HRRs, we identified facilities providing high (N = 2 NHs) and low (N = 2 NHs) intensity care relative to all NHs in that HRR (N = 16 total facilities; 4 facilities/HRR).
To date, the research team conducted 275 h of observation in 13 NHs and interviewed 158 NH providers from varied disciplines to assess physical environment, care processes, decision-making processes, and values. We interviewed 44 proxies (black, N = 19; white, N = 25) about their perceptions of advance care planning, decision-making, values, communication, support, trust, literacy, beliefs about death, and spirituality. This report describes ADVANCE
study design and the facilitators and challenges of its implementation, providing a template for the successful application of large qualitative studies focused on quality care in NHs.