Preventing the Calcium Channel Blocker – Lower Extremity Edema – Loop Diuretic Prescribing Cascade in Older Adults

项目摘要。处方级联（PC），其中药物诱导的不良事件（AE）导致 一个中心问题是增加治疗，而不是减少处方或剂量 在老年人综合用药方面。不像其他药物组合，应避免，如药物-药物 由于存在交互，因此目前没有向PC提供商发出警报的流程。为了防止或取消个人电脑， 提供者必须评估复杂的药物治疗方案和多种慢性疾病， 药物引起的AE。适当的设计和实施临床决策支持（CDS）提供了一个 有前途的方法，以提高及时检测的PC。在这项工作中，我将使用一个研究框架， 评估个人电脑和发展的CDS工具，在临床实践中检测，使用的例子，大概 常见和有问题的PC：钙通道阻滞剂相关的下肢水肿，导致 服用袢利尿剂（CCB LEE袢利尿剂）。我的具体目标包括（目标1）估计 以及评估哪些人群是CCB的最高风险人群，（目标2）量化 额外AE、医疗保健利用和与CCB BLEE BLEE Loop PC相关的成本，以及（目标3） 开发并验证用于CDS的CCB BLEE循环PC算法，以前瞻性识别 个人与PC NIA K 08提案将为培训和研究成果奠定基础， 建立一个独立的研究项目，打击老年人的多种药物，特别关注 尽量减少不必要的药物使用。我在老年临床药学方面的丰富经验和我的作用 作为佛罗里达大学（UF）健康医生的药房服务助理主任， UF健康的做法，将确保深临床背景和这项工作的相关性。我最初接触到的 观察研究方法和经验与医疗保险数据在我的博士培训将是 通过这个K奖在与拟议工作相关的三个不同领域得到加强：（1） 药物流行病学方法，包括使用先进的纵向分析， 药物作用的推断，（2）CDS的开发和验证，以及（3）实施科学。UF健康 是东南部最大的完全集成的学术健康中心，其卓越的大数据基础设施 为实现拟议目标和我的长期目标提供了理想的环境。温特斯坦医生 我将指导我的药物流行病学培训，并领导一个由以下人员组成的多学科导师团队 CDS开发和实施以及药物效果经济评价方面的专家（马龙博士）， (Dr. Manini）、生物统计学（Brumback博士）、高血压临床管理（Pepine博士）、临床老年病学 (Dr. Solberg），以及警报的制定、评估和实施（Staley博士）。综合辅导 研究经验和培训将使我能够竞争R 01基金，重点是CDS的实施 并建立一个独立的研究项目，以打击老年人的多种药物。

PROJECT SUMMARY. Prescribing cascades (PCs), in which drug-induced adverse events (AEs) result in additional treatment rather than deprescribing or dose reduction of the offending agent, are a central problem in geriatric polypharmacy. Unlike other drug combinations that should be avoided, such as drug-drug interactions, there is currently no process that alerts providers of PCs. To prevent or deprescribe PCs, providers must evaluate complex medication regimens and multiple chronic conditions that may contribute to drug-induced AEs. Appropriate design and implementation of clinical decision support (CDS) offers a promising approach to enhance timely detection of PCs. In this work, I will use a research framework that evaluates PCs and develops CDS tools for detection in clinical practice, using the example of a presumably common and problematic PC: calcium channel blocker-associated lower extremity edema leading to the prescribing of a loop diuretic (CCBLEELoop). My specific aims include (Aim 1) estimating the incidence and evaluating which populations are at highest risk of CCBLEELoop PC, (Aim 2) quantifying excess AEs, healthcare utilization, and costs associated with the CCBLEELoop PC, and (Aim 3) developing and validating a CCBLEELoop PC algorithm for use in CDS to prospectively identify individuals with the PC. This NIA K08 proposal will lay the foundation, both in training and research output, for building an independent research program that combats polypharmacy in older adults, with particular focus on minimizing unnecessary medication use. My extensive experience in geriatric clinical pharmacy and my role as the Assistant Director of Pharmacy Services with University of Florida (UF) Health Physicians, the faculty practice of UF Health, will ensure deep clinical context and relevance of this work. My initial exposure to observational research methods and experience with Medicare data during my doctoral training will be enhanced through this K award in three distinct areas relevant to the proposed work: (1) pharmacoepidemiologic methods including the use of advanced longitudinal analyses to make causal inferences on drug effects, (2) development and validation of CDS, and (3) implementation science. UF Health is the largest fully-integrated academic health center in the Southeast and its excellent big data infrastructure provides an ideal environment for achieving the proposed objectives and my long-term goals. Dr. Winterstein will guide my training in pharmacoepidemiology and lead a multidisciplinary mentorship team composed of experts in CDS development and implementation and economic evaluation of drug effects (Dr. Malone), aging (Dr. Manini), biostatistics (Dr. Brumback), clinical management of hypertension (Dr. Pepine), clinical geriatrics (Dr. Solberg), and alert development, evaluation, and implementation (Dr. Staley). The integrated mentored research experience and training will allow me to compete for R01 funding focused on CDS implementation and build an independent research program that combats polypharmacy in older adults.