Dying While Poor: Investigating Multi-level Determinants of Inequities in End-of-life Care for Adults with Heart Failure

About This Grant

The Medicare Hospice Benefit, which dictates hospice policy for most Americans, was designed based on the needs of people with cancer, a disease with a trajectory vastly different from that of heart failure (HF). Implicit in the Medicare Hospice Benefit is the assumption that people have the supports necessary to facilitate a home death. Yet, individuals with fewer financial and social resources, who experience the greatest HF morbidity and mortality, are less likely to use hospice and die at home than individuals with greater resources. Dr. Cross’s long-term career goals are 1) to use patient-centered mixed methods to identify and understand the end-of-life experiences of people with HF and 2) to develop interventions that address differences in end-of-life HF care outcomes through practice and policy change. This K01 project includes three specific aims. Aim 1 will use hierarchical multiple regression to characterize the influence of individual and hospital level factors on end-of-life HF care. Aim 2 will incorporate geographically bounded areas into hierarchical multiple regression to quantify the impact of neighborhood-based attributes on end-of-life HF care. Aim 3 will explore end-of-life HF needs and perceived opportunities to receive optimal care among adults with HF, their caregivers, and clinicians through semi-structured interviews. Dr. Cross will strengthen and address gaps in her experience through the following career development objectives: 1) acquire increased proficiency in mixed methods research, 2) develop expertise in advanced analytic methods for health outcomes research, 3) advance her understanding of the management of patients with advanced HF and the role of hospice and palliative care within the HF trajectory, and 4) acquire skills in designing, conducting, and evaluating socio-behavioral interventions. This proposal lays out a comprehensive career development plan consisting of expert mentorship, specialized coursework, and completion of a research project. Dr. Cross’s development during this four-year award will be guided by an interdisciplinary team of mentors at Emory University, led by Dio Kavalieratos, PhD, Associate Professor and Director of Research for the Division of Palliative Medicine; Neal Dickert, MD, PhD, the Thomas R. Williams Professor of Medicine in the Division of Cardiology; Shivani Patel, PhD, MPH, Associate Professor of Public Health in the Departments of Global Health and Epidemiology; and Modele Ogunniyi, MD, MPH, Professor of Medicine in the Division of Cardiology. This research training and career development plan will support Dr. Cross in achieving her goal of becoming an independent investigator in supportive cardiology and will inform the development of evidence-based solutions to improve end-of-life HF care.