Background
As the population of older adults continues to increase, the prevalence of diseases and conditions common in aging is expected to rise. Cardiovascular diseases, cancer, chronic lung diseases, dementia, and chronic kidney disease will likely continue to be the greatest contributors to morbidity and mortality, as well as the costliest conditions to healthcare systems. However, older Americans infrequently have just one chronic health condition. In 2017, over two-thirds of Medicare beneficiaries had more than one chronic condition, and over 17% had six or more chronic conditions. Disability and greater care needs associated with these conditions is leading to an increase in residence in nursing homes and other long-term care facilities. Healthcare costs will continue to grow, with health-related spending expected to reach nearly 20% of gross domestic product by 2027.
Serious illnesses resulting from the progression of chronic health conditions pose particular challenges for healthcare decision-making. While treatments with curative intent may forestall complications and relieve some symptoms, disease progression ultimately leads to increased disability and symptom burden that compromise quality of life. In addition, among patients with multiple morbidities, treatments for co-occurring conditions may antagonize each other (also known as therapeutic competition), and patients must evaluate trade-offs among multiple sub-optimal treatment options. As a result, patients' values, preferences, and goals become essential to inform care decisions.
Providing care that is consistent with a patient's values, preferences, and goals is a cornerstone of palliative care. Palliative care focuses on several objectives, including relief of symptoms and suffering, communication of prognosis and treatment options in the context of patients' goals, and coordination of care within and across healthcare settings. Palliative care is not synonymous with hospice or end-of-life care. Rather, the latter are parts of the spectrum of care for serious illness that is addressed by palliative care, from diagnosis through terminal stages of disease. Moreover, palliative care does not necessarily entail withholding or curbing treatment. Relief of symptoms, enhancing quality of life, and other specific aspects of goal-concordant care may involve optimal medical or surgical treatment of disease. Furthermore, proactive approaches to disease management, such as prehabilitation strategies prior to surgery to improve functional recovery, can be consistent with goal-concordant care. However, without knowing patients' values and preferences, care may be inconsistent or even run counter to patients' goals.
Scope
This Notice of Special Interest (NOSI) encourages research grant applications focused on palliative care in geriatric populations. This NOSI covers studies in a variety of settings including hospitals (and specific sites within hospitals including specialty medical or surgical wards, intensive care units, and emergency departments), post-acute care settings, outpatient clinics and doctors' offices, patients' homes and other residential settings, long-term care facilities, hospices, and other healthcare or community settings. This NOSI encourages both prospective studies and analyses of existing datasets, health and medical records, claims data, or other sources. Leveraging ongoing cohorts, intervention studies, networks, data and specimen repositories, and other existing research resources and infrastructure is encouraged. Study designs may include observational approaches, quasi-experimental designs, and interventional studies.
Topics of interest among Institutes and Centers (ICs) participating in this NOSI are summarized below. Applicants are encouraged to contact the Scientific/Research contacts listed below to ensure that proposed aims are consistent with the mission(s) of the intended IC(s). Where IC topic areas overlap, applicants are especially encouraged to contact the respective IC representatives to discuss appropriate arrangements for dual assignment.
National Cancer Institute (NCI)
The NCI is interested in studies that focus on advancing the science of geriatric palliative care in the context of cancer patients, cancer populations, and other persons affected by cancer. Examples of studies of interest include, but are not limited to, the following:
- Analyze and compare biological, social, and psychological factors that place aging patients at risk for poor outcomes (e.g., decreased survival, serious adverse events) during and following cancer treatment.
- Examine the trajectory of physical and functional abilities during cancer treatment.
- Develop and refine interventions that improve older patients' tolerance of and adherence to cancer therapies.
- Examine physician and patient factors that contribute to treatment decision-making (e.g., enrolling in cancer clinical trials, implementing dose reductions of cancer therapies).
- Develop, test, and evaluate interventions that aim to deliver timely, effective, patient-centered palliative care to older adults diagnosed with cancer.
- Develop, test, and evaluate cancer care delivery models for older adults with cancer, including those that allow for the provision of palliation simultaneously with active treatment, including clinical trial participation.
- Identify and address the palliative care needs of special cancer patient populations who may be medically underserved by palliative care, including older adults with comorbid conditions and individuals being treated for less common cancers and hematologic malignancies.
- Expand knowledge of the efficacy of interventions known to be effective at earlier places along the cancer continuum to manage common cancer symptoms at the end of life.
- Develop and test tools, multilevel interventions, care delivery models, and health IT features that facilitate the communication of advanced care planning documents among primary, specialty, and acute care providers, and the development of shared understanding of the care plan and interdependencies involved among older adults, family members, caregivers, physicians, healthcare practitioners, and healthcare organizations who care for older adults with cancer.
- Test the feasibility, acceptability, reach, and effectiveness of telehealth and eHealth palliative care services for older adults diagnosed with cancer, particularly those in medically underserved communities.
- Develop interventions to build and strengthen cancer palliative care capacity among healthcare providers across the spectrum of healthcare delivery settings.
- Develop feasible and effective approaches to collect patient-generated health data, including patient-reported outcomes (PROs) from older adults with advanced cancers, including patients with limited health literacy and technology access.
- Develop feasible and effective approaches to evaluate the quality of palliative care provided to older adults with cancer and comorbid conditions.
- Develop and test methods in data collection and data analysis to address missing outcomes data in palliative care intervention studies of older adults with cancer (e.g., missing due to attrition, patient condition precluding completion of PRO measures), including use of proxy outcome evaluators and clinician-rating scales.
- Examine prognostic understanding and awareness among older adult cancer patients from the initiation of palliative care to end-of-life, as well as how patients' prognostic understanding relates to family members' and caregivers' prognostic understanding and how patient and family beliefs relate to oncologist-provided prognoses.
- Develop, test, and evaluate intervention approaches implemented across different healthcare systems and community settings that encourage palliative care interventions based on older cancer patients' health status, not age.
- Develop, test, and evaluate intervention approaches (from initiation of palliative care to end-of-life) implemented across different healthcare systems and community settings that are based on older cancer patient's health status, not age.
Note: For this NOSI, NCI participates in the following FOAs:
- PAR-18-559 - Cancer Prevention & Control Clinical Trials Grant Program (R01 Clinical Trial Required)
- PAR-19-356 - NCI Clinical & Translational Exploratory/Developmental Studies (R21 Clinical Trial Optional)
- PA-19-056 - NIH Research Project Grant (Parent R01 Clinical Trial Not Allowed)