Associations of Opioid Prescribing with Long-term Functional Outcomes and Mortality Rates in Older Nursing Home Residents

项目摘要 处方阿片类药物的使用在养老院（NH）环境中的老年人中越来越常见。一个全国 所有长期停留的代表性横断面研究（即，2018年发表的年龄≥90天的NH居民发现， 三分之一（32.4%）的人在任何时间段内服用阿片类药物，七分之一（15.5%） 长期使用阿片类药物（即，≥90天）。阿片类药物处方与长期- 长期认知和身体功能结果，以及阿片类药物处方和死亡率之间的关系， 在老年NH居民中-也许是阿片类药物使用者中最脆弱，风险最高的群体-主要是 未开发的拟议的全国性研究通过调查明确解决了这些知识差距 按作用持续时间开阿片样物质处方（即，长效与短效阿片类药物）及其与 老年NH居民的长期功能结局和死亡率。 使用医疗保险和医疗补助服务中心的2018-2019年医疗保险索赔（例如，A、B和D部分） 数据链接到1）最小数据集（MDS）3.0，联邦要求的所有居民居住的临床评估 在医疗保险或医疗补助认证的NH季刊中，2）公开可用的NH水平数据（例如，认证和 调查提供者增强报告（CASPER）和护理之家比较），以及3）国家死亡指数 (NDI)数据，这项拟议的研究具有以下具体目标：1）检查发病率和患病率 老年NH居民中按作用持续时间列出的阿片类药物使用率; 2）确定居民和机构层面的因素 与NH环境中的阿片类药物处方相关; 3）研究短效与 与长期相关的长效阿片类药物（a）功能结果的变化（例如，认知障碍， 虚弱和疼痛）和（B）老年NH居民的阿片类药物相关和全因死亡率。为了确保严格的 研究，我们将进行长期使用的敏感性分析（例如，≥90天）、最大日剂量（例如，≥90 吗啡毫克当量），以及伴随使用阿片样物质增效剂（例如，苯二氮卓类， 加巴喷丁类化合物），使用纵向数据分析（即，线性混合建模和生存分析）。我们的研究 还将采用倾向评分匹配和工具变量方法来调整潜在的观察到的 和未观察到的混杂因素。 迄今为止，有两个关于阿片类药物处方的联邦指南，但它们在很大程度上忽视了老年人 生活在NHS 2019年，美国国家科学、工程和医学院（NASEM）召开了一次会议， 制定阿片类药物处方指南的专家小组。其中一项建议是进行研究 调查患者和人群水平的长期健康结果。拟议的研究是及时的 并直接处理了这一建议。拟议研究的结果将进一步指导更安全的阿片类药物 使用在老年人生活在NH设置。

Project Abstract Prescription opioid use is increasingly common in older adults in nursing home (NH) settings. A nationally representative cross-sectional study of all long-stay (i.e., ≥90 days) older NH residents published in 2018 found that one in three (32.4%) were prescribed an opioid medication for any duration, and one in seven (15.5%) were prescribed opioids for long-term use (i.e., ≥90 days). Relationships between opioid prescribing and long- term cognitive and physical functional outcomes, as well as between opioid prescribing and mortality rates, among older NH residents—perhaps the most vulnerable, highest-risk group of opioid users—are largely unexplored. The proposed nationwide study explicitly addresses these knowledge gaps through investigating opioid prescribing by duration of action (i.e., long-acting versus short-acting opioids) and their associations with long-term functional outcomes and mortality rates among older NH residents. Using the Centers for Medicare and Medicaid Services’ 2018-2019 Medicare claims (e.g., Part A, B, and D) data linked to 1) Minimum Data Set (MDS) 3.0, a federally required clinical assessment of all residents residing in Medicare- or Medicaid-certified NHs quarterly, 2) publicly available NH-level data (e.g., Certification and Survey Provider Enhanced Reporting (CASPER) and Nursing Home Compare), and 3) National Death Index (NDI) data, this proposed study features the following specific aims: 1) to examine incidence and prevalence rates of opioid use by duration of action in older NH residents; 2) to identify resident- and facility-level factors associated with opioid prescribing in NH settings; and 3) to investigate differential risks of short-acting versus long-acting opioids associated with long-term (a) changes in functional outcomes (e.g., cognitive impairment, frailty, and pain) and (b) opioid-related and all-cause mortality rates in older NH residents. To ensure a rigorous study, we will conduct sensitivity analyses by long-term use (e.g., ≥90 days), maximum daily dose (e.g., ≥90 morphine milligram equivalents), and concomitant use of opioid potentiators (e.g., benzodiazepines and gabapentinoids), using longitudinal data analyses (i.e., linear mixed modeling and survival analysis). Our study will also employ propensity-score matching and instrumental variable methods to adjust for potential observed and unobserved confounders. To date, there are two federal guidelines on opioid prescribing, but they largely overlooked older adults living in NHs. In 2019, the National Academies of Science, Engineering, and Medicine (NASEM) convened an expert panel group that framed opioid prescribing guidelines. One recommendation was to conduct research investigating the long-term health outcomes in both patient and population levels. The proposed study is timely and directly addresses this recommendation. Findings from the proposed study will further guide safer opioid use in older adults living in NH settings.