Identifying Approaches to Measure and Reduce Harmful, Low-Value Care Among Older Americans with Mild Cognitive Impairment and Dementia

摘要 低价值护理是指在特定的临床方案中不提供净收益的患者护理，通常会导致 伤害。患有轻度认知障碍和痴呆症(MCID)的老年人经常接受低价值的护理和 特别容易受到其危害(例如，常规的苯二氮卓类药物处方对 患有MCID的成年人，可导致精神错乱或跌倒)。减少低价值医疗服务的提供可以改善健康 通过减少对伤害的暴露以及减少不必要的伤害来为这一弱势群体带来结果 花销。要开始减少患有MCID的老年人的低价值护理提供问题，重要的是 了解国家问题的严重程度，确定患者的特征和分娩系统 风险敞口最大，以及目前实施的两项美国战略(支付改革和 在患有MCID的老年人中，低价值护理的提供较少。 在这方面，我们提出了三个具体目标：1)产生国家对低价值护理趋势的估计， 对患有MCID的老年人的成本和危害(2008-2018)，2)在以下位置识别患有MCID的老年人亚群 接受低价值护理的最大风险，以及3)评估两个美国战略是否相关 对患有MCID的老年人提供的低价值护理较少。 我们建议通过将联邦医疗保险索赔数据与健康和退休研究联系起来来实现这些目标 (HRS)，这是一项具有全国代表性的关于社区居住和机构化老年人的纵向研究 美国人对老龄化的健康和经济变化的看法。我们将利用国家机构实现这些目标 并通过应用严格的分析方法，如中断时间序列方法 同期对照组。最终，我们寻求建立一个证据基础，以告知未来的美国。 健康政策，可以减少低价值的护理，改善以患者为导向的老年美国人的结果 MCID。

ABSTRACT Low-value care is patient care that provides no net benefit in specific clinical scenarios, and often causes harm. Older adults with mild cognitive impairment and dementia (MCID) frequently receive low-value care and are particularly vulnerable to its harms (e.g., routine benzodiazepine drug prescriptions offer limited benefit to adults with MCID and can cause delirium or falls). Reducing the delivery of low-value care can improve health outcomes for this vulnerable group by lessening exposure to harms as well as curtailing unnecessary spending. To begin to reduce the problem of low-value care delivery in older adults with MCID, it is important to understand the extent of the national problem, identify the characteristics of patients and the delivery systems with the greatest risk exposure, and whether two currently implemented U.S. strategies (payment reform and a large education campaign) were associated with less delivery of low-value care among older adults with MCID. In this context, we propose three specific aims: 1) to generate national estimates of low-value care trends, costs, and harms in older adults with MCID (2008–2018), 2) to identify subgroups of older adults with MCID at the greatest risk of receiving low-value care, and 3) to assess whether two U.S. strategies were associated with less low-value care delivered to older adults with MCID. We propose to achieve these aims by linking Medicare claims data with the Health and Retirement Study (HRS), which is a nationally representative longitudinal study of community-dwelling and institutionalized older Americans on the health and economic changes of aging. We will pursue these aims using national longitudinal data and by applying rigorous analytical approaches such as interrupted time series methods with contemporaneous control groups. Ultimately, we seek to build a foundation of evidence to inform future U.S. health policies that can reduce low-value care and improve patient-oriented outcomes in older Americans with MCID.