Health Disparities in Timely Goals of Care Discussions and Hospitalizations Due to Infections in Nursing Home Residents

Over 1.3 million residents live in the 15,600 nursing homes (NHs) across the nation. About 90% of NH residents are 65 years of age or older and more than 50% are in their final stage of life, emphasizing the role of NHs as important end-of-life care settings. In addition, NH residents are highly susceptible to infections with approximately 2.7 million infections occurring every year and more than 380,000 residents dying of infections. Indeed, about 50% of NH residents were transferred to acute care hospitals due to suspected infections, and up to 55% of these hospitalizations were identified as potentially avoidable. Furthermore, Black and Hispanic residents are more likely to receive suboptimal palliative care and have higher rates of hospitalizations due to infections compared to non-Hispanic and White residents. Therefore, it has been recommended that Timely Goals of Care (TGOC) discussions occur early and be evaluated periodically throughout the care trajectory for clinicians to provide goal-concordant care at the end-of-life. In the Study of Infection Management and Palliative Care at End-of-Life (SIMP-EL; R01 NR013687; Stone PI and sponsor) researchers identified wide variations across NHs regarding when residents and/or family preferences for care were elicited. However, no one has examined how TGOC discussions vary in NHs by race and ethnicity, and other social determinants of health including resident, facility, and community level characteristics. Also, the relationships between TGOC discussions and hospitalizations due to infections are not known. The proposed study will address these gaps through a secondary analysis of cross-sectional datasets using multiple data sources including: 1) the SIMP- EL survey for TGOC discussions; 2) the Minimum Data Set 3.0 for NH resident assessments; 3) the Medicare Provider and Analysis Review for hospital claims data; and 4) other publicly available data sources (e.g., American Community Survey) for facility and community characteristics. Guided by an integrated conceptual framework using the Donabedian and Minority Access to End-of-Life Care Models, the specific aims are to: (1) identify differences in the TGOC discussions in NHs by resident, facility, and community characteristics, and (2) determine the association between TGOC discussions and hospitalizations due to infections and examine differences by resident, facility, and community characteristics. The proposed aims are aligned with the National Institute of Nursing Research's research focus on end-of-life care and health disparities. To facilitate this research, the applicant will advance her knowledge and understanding on palliative care research related to infection outcomes in long-term care settings, health disparities related to end-of-life care processes, and quantitative research methods. With the dedicated mentorship and the resource-rich environment of Columbia University, the applicant will build a strong foundation from which to move toward her long-term goal of becoming an independent nurse scientist who develops research evidence that informs health policies and guidelines to ensure timely, accessible, and equitable end-of-life care for all.