National Institute on Aging grant supports research into complex interplay of medication and symptoms
Jennifer Tjia, MD, MSCE, has focused her career on trying to untangle signs of the impending end of a person’s life from confounding factors such as incorrect medication.
Dr. Tjia, professor of population & quantitative health sciences, recently received a midcareer development and research grant from the National Institute on Aging. She will study nursing home residents in hospice care across the country, to inform the design of tools that identify when residents are entering the final stages of life and interventions to optimize medication use at that time. The $991,910, five-year grant also supports mentorship of trainees from varied disciplines committed to aging research.
Hospice care, which is covered under a special Medicare benefit, covers palliative care for people with a terminal illness. Covered care is designed to make them comfortable and in control of their symptoms, but not aimed at curing the illness. Hospice care also includes support for a patient’s social, emotional, spiritual and family needs, including grief counseling.
To qualify for hospice, a patient must have a life expectancy of less than six months and be willing to forgo further curative treatment options for their illness. Patients who live beyond six months may continue to receive hospice benefits, as long as their physician recertifies that they are terminally ill.
“It’s not uncommon for it to look like it’s the end of life and enter hospice, and then we peel back all these medications that they’re on and the person wakes up and they go on to live for six months, a year, or longer,” Tjia said. “And that’s not something that’s easily studied with traditional study designs or data.”
Multiple disciplines are needed to figure out the complex interplay between medications, symptoms and end-of-life signs, she said, including expertise in pharmacology and biostatistics.
Almost 1.3 million adults 65 or over die with hospice each year. Among all hospice deaths in the Medicare system, 17.4 percent occur in a nursing facility, Tjia said.
Tjia and the junior researchers she mentors will work with enormous datasets for all the nursing homes in the country over a span of several years, linking Medicare medication claims and symptoms that go along with prescriptions. They will report on the number of unnecessary medications that people who die in nursing homes are using, the trajectory of declines in function or increasing symptom burden, and increasing medication burden over time before people die, among other factors.
Tjia’s research also looks at qualitative components to determine the extent to which operational factors, such as nursing home staffing levels and areas of expertise, may play a role in identifying barriers and needs for appropriate end-of-life care. She also hopes to learn more about reasons for resistance to entering hospice among nursing home residents.
All this will come together in a report Tjia described as “an analysis trying to understand what factors predict who gets into hospice or not; is it really patient driven? Is it the accumulation of complicated symptoms and complicated meds, which I think some people would say is an appropriate reason for having hospice? Or are there other factors driving nursing home residents to go into hospice that are more policy or economically driven, and less patient-care focused?”
Tjia continued: “The equally fun part is helping people launch their career on this important topic. We want people to advance the field of geriatric palliative care. And we need lots of people with different clinical and research backgrounds to come out and commit to this work, and that’s what’s cool about this grant: It really sees the need for interprofessional research.”