Optimizing Medical Decision Making for Older Patients with Type 2 Diabetes

工程摘要 老年患者2型糖尿病（T2D）的管理目前因缺乏所需证据而受到阻碍 为有效的医疗决策提供信息老年糖尿病患者具有高度异质性， 关于预期寿命、糖尿病持续时间、合并症、糖尿病并发症、残疾、功能 损伤和治疗偏好。目前的临床指南都承认这种异质性， 支持个体化糖尿病护理的概念，但就如何 个体化血糖目标和药物治疗方案。这些冲突反映了缺乏证据表明， 在现实世界的临床治疗，健康状况和医疗决策之间的动态相互作用 实践人口。虽然病人的观点是共同决策的支柱，但人们对 老年患者的治疗偏好和当前糖尿病治疗经验的变化， 包括自我管理障碍和自我报告的药物不良事件。同样， 关于A1 C与关键结果之间的关系如何因医疗复杂性和类别而变化 降糖药此外，忙碌的临床医生缺乏实用的、基于证据的工具来指导决策 制定个性化的目标和药物。我们的首要目标是进行观测 研究提供所需的证据，为T2D老年人提供安全有效的护理。本研究 将基于145，894例≥65岁的T2D患者的充分表征的多种族人群， 北方加州的凯撒医疗机构。我们将使用一项由NIA资助的调查（R56 AG051683）的结果， 约6，000例患者的年龄分层随机样本，以描述患者对治疗的看法 偏好、自我管理障碍和患者相关结果（例如，低血糖、福尔斯、生活质量）。 在这项拟议的研究中，我们将把调查答复与基于EMR的暴露和结果联系起来（例如，实验室， 药物处方和依从性、并发症、死亡率）。这将使我们能够描述 老年患者对糖尿病治疗的经验和偏好，并检查 患者偏好与自我管理障碍之间的关系， 使用和结果（目标1）。为了告知建立适当血糖目标的努力，我们将确定A1C 与关键不良糖尿病结局（微血管和大血管）风险最低相关的水平 并发症、死亡率和低血糖），按健康状况、年龄、糖尿病病程和药物治疗分层 类型（目标2）。最后，我们将创建一个决策支持工具，以鼓励糖尿病护理的个性化， 在老年T2D患者中，最大限度地提高安全性并尽量减少过度治疗（目标3）。这种努力包括 开发和验证当代死亡率预测模型，并将其与我们现有的 低血糖风险分层模型。拟议研究的完成将确保老年患者 并且他们的提供者具有对糖尿病做出明智决定所必需的临床证据和支持。

Project Abstract Management of type 2 diabetes (T2D) in older patients is currently hampered by the lack of evidence needed to inform effective medical decision making. Older patients with diabetes are highly heterogeneous with regards to life expectancy, duration of diabetes, comorbidities, diabetic complications, disabilities, functional impairments, and treatment preferences. Current clinical guidelines all acknowledge this heterogeneity and support the concept of individualized diabetes care, but provide conflicting recommendations regarding how to individualize glycemic targets and medication regimens. These conflicts reflect the lack of evidence regarding the dynamic interactions between treatments, health status, and medical decision making in real-world clinical practice populations. While the patient perspective is a pillar of shared decision making, little is known about the variation in older patients' treatment preferences and experiences with current diabetes treatments, including self-management barriers and self-reported adverse drug events. Similarly, basic evidence is lacking on how the relationship between A1C and key outcomes varies by medical complexity and by classes of glucose-lowering medications. Moreover, busy clinicians lack practical, evidence-based tools to guide decision making regarding individualized targets and medications. Our overarching goal is to conduct observational research to provide evidence needed to inform safe and effective care of older adults with T2D. This research will be based on a well-characterized, multi-ethnic population of 145,894 patients ≥65 years old with T2D from Kaiser Permanente Northern California. We will use the results of a NIA-funded survey (R56 AG051683) in an age-stratified, random sample of ~6,000 patients to characterize patient perspectives on treatment preferences, self-management barriers, and patient-related outcomes (e.g., hypoglycemia, falls, quality of life). In this proposed study, we will link survey responses to EMR-based exposures and outcomes (e.g., labs, medication prescribing and adherence, complications, mortality). This will allow us to characterize variation in older patient's experiences with and preferences for diabetes treatments and examine the relationships between patient preferences and self-management barriers with past or future glycemic control, medication use and outcomes (Aim 1). To inform efforts to establish appropriate glycemic targets, we will identify A1C levels that are associated with the lowest risk of key adverse diabetes outcomes (micro- and macrovascular complications, mortality, and hypoglycemia), stratified by health status, age, diabetes duration, and medication type (Aim 2). Finally, we will create a decision support tool to encourage the individualization of diabetes care, maximizing safety and minimizing overtreatment, in older adults with T2D (Aim 3). This effort includes developing and validating a contemporary mortality prediction model and integrating it with our existing hypoglycemia risk stratification model. The completion of the proposed studies will ensure that older patients and their providers have the clinical evidence and support necessary to make informed decisions for diabetes.