Developing a framework to individualize surgical decision-making for older adults with primary hyperparathyroidism

项目总结/摘要 这个K76职业发展奖将解决患者特定决策支持的大量未满足需求 为老年人手术干预提供工具，并为申请人成为 老年外科原发性甲状旁腺功能亢进（PHPT）是老年人常见的内分泌疾病， 与严重的长期发病率相关，包括骨质疏松性骨折、肾结石和慢性 肾病（CKD）。甲状旁腺切除术可以预防这些病态后遗症。然而，增加的外科手术 与高龄和虚弱相关的风险，除了在实现之前死亡的竞争风险之外， 受益于手术干预，提出了一个问题，是否甲状旁腺切除术的短期风险 超过了这一组的长期风险降低。确定老年人可能受益于手术 干预措施，如甲状旁腺切除术，同时防止过度使用手术在这个脆弱的群体， 对改善以病人为中心的护理至关重要。目前，还没有标准化的方法来开发 结合个体化风险预测和利益相关者输入的老年人手术决策支持 促进知情的、以患者为中心的决策。因此，这次协同调研和培训， 提案旨在：1）比较甲状旁腺切除术与药物治疗对 骨折、症状性肾结石和CKD的老年PHPT患者; 2）开发并验证预测性 甲状旁腺切除术的围手术期风险和骨折、肾结石的长期风险模型， 慢性肾脏病特定于老年人与PHPT;和3）设计和测试与利益相关者的反馈PHPT的决定 描述甲状旁腺切除术与非手术治疗的权衡的支持工具。完成 为了实现这些目标，Seib博士将接受比较有效性和预测建模、定性和 混合方法研究，以发展决策支持和实施科学。在完成此 研究，Seib博士将有一个用户测试的风险/效益计算器，将形成决策支持的基础 工具，以改善个性化，以患者为中心的治疗建议，老年人与PHPT。在 此外，本研究将建立一个框架，发展以病人为中心的决策支持， 适用于其他条件，以促进老年人的适当手术管理。这项建议是 重要的是，它直接解决了PHPT和其他外科手术决策支持工具中的差距， 老年人的管理条件。这个项目是创新的，因为它提出了一个范式转变， 结合老年医学原则，对老年PHPT患者进行个体化治疗决策，以优化临床 结果。在拟议的研究结束时，Seib博士将拥有成功完成研究所需的数据和技能。 寻求R01资金用于混合1型有效性实施试验，以测试该决策支持工具， 将这种方法应用于影响老年人的其他手术治疗选择。

PROJECT SUMMARY/ABSTRACT This K76 Career Development award will address the large unmet need for patient-specific decision support tools for surgical interventions in older adults and provide a platform for the applicant to become a leader in geriatric surgery. Primary hyperparathyroidism (PHPT) is a common endocrine disorder in older adults that is associated with serious long-term morbidity, including osteoporotic fractures, kidney stones, and chronic kidney disease (CKD). Parathyroidectomy can prevent these morbid sequelae. However, increased surgical risk associated with advanced age and frailty, in addition to the competing risk of death prior to achieving benefit from surgical intervention, raises the question of whether the short-term risks of parathyroidectomy outweigh long-term risk reduction in this group. Identifying older adults likely to benefit from surgical interventions, such as parathyroidectomy, while preventing overuse of surgery in this vulnerable group, is critical to improve patient-centered care. Currently, there is no standardized methodology for developing surgical decision support for older adults that incorporates individualized risk prediction and stakeholder input to facilitate informed, patient-centered decision-making. Therefore, this coordinated research and training proposal aims to: 1) compare the effects of parathyroidectomy vs. medical management on the incidence of fractures, symptomatic kidney stones, and CKD in older adults with PHPT; 2) develop and validate predictive models for the perioperative risks of parathyroidectomy and long-term risks of fractures, kidney stones, and CKD specific to older adults with PHPT; and 3) design and test with stakeholder feedback a PHPT decision support tool that describes the tradeoffs of parathyroidectomy vs. non-operative management. To accomplish these aims, Dr. Seib will obtain training in comparative effectiveness and predictive modeling, qualitative and mixed methods research to develop decision support, and implementation science. Upon completion of this research, Dr. Seib will have a user-tested risk/benefit calculator that will form the basis of a decision support tool to improve individualized, patient-centered treatment recommendations for older adults with PHPT. In addition, this research will establish a framework for developing patient-centered decision support that can be applied to other conditions to promote appropriate surgical management of older adults. This proposal is significant because it directly addresses the gap in decision support tools for PHPT and other surgically managed conditions in older adults. This project is innovative because it proposes a paradigm shift to incorporate geriatric principles to individualize treatment decisions in older adults with PHPT to optimize clinical outcomes. At the end of the proposed research, Dr. Seib will have the data and skills necessary to successfully pursue R01 funding for a hybrid type 1 effectiveness-implementation trial to test this decision support tool and apply this methodology to other conditions with surgical treatment options that affect older adults.