Optimizing prescribing decisions for hospitalized older adults with chronic conditions

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PROJECT SUMMARY/ABSTRACT Over 7 million adults ages 65 and older are hospitalized in the US annually, of whom two-thirds have multiple chronic conditions. Older adults are often discharged with changes to medications for chronic conditions, such as hypertension and diabetes, which are not directly related to their reason for hospitalization. In current practice, neither prior chronic disease control nor key geriatric issues such as multimorbidity, polypharmacy, or cognition appear to influence discharge prescribing decisions. There is an urgent need to reorient the current approach to hospital management of older adults’ chronic conditions from a number-driven to a patient- centered decision-making process. Treatment guidelines have not been designed to inform decisions for hospitalized older adults, who more often face multimorbidity and, while recovering from acute illness, may face transient cognitive and functional decline and long-term changes in prognosis that impact both risks and benefits of chronic disease medications. Although substantial efforts have been made to improve discharge medication reconciliation, little focus has been placed on understanding clinician rationale for changing chronic medications or patient rationale for non-persistence to changes, which may include ADEs or poor communication of changes. My long-term goal is to become a national leader in improving the safety and quality of chronic disease management for older adults across transitions of care. The objectives of this proposal are to conduct a prospective cohort study to address current knowledge gaps on the clinician rationale for chronic medication changes prescribed at discharge and subsequent patient outcomes. This novel information will inform the development and pilot testing of a clinical decision framework which will incorporate geriatric principles to individualize discharge prescribing decisions for hospitalized older adults, focusing on 2 exemplar conditions: hypertension and diabetes. Mentored by a superb team of experts in aging research, hospital medicine, pharmacoepidemiology, and clinician-focused intervention development, I will: 1) Conduct a prospective mixed-methods cohort study of older adults discharged from the hospital with chronic medication changes to evaluate clinician’s reasons for making medication changes, older adults' understanding of changes, and patient-reported outcomes following changes; 2) Develop and refine a clinical decision framework for individualizing discharge diabetes and hypertension prescribing decisions for hospitalized older adults 3) Conduct a pilot pretest-posttest trial to learn if providing the clinical decision framework tool to facilitates self-efficacy to individualize prescribing decisions and leads to improved patient understanding of medication changes. This proposal will produce an innovative geriatrics-informed approach for chronic condition prescribing decisions for hospitalized older adults. Completion of the proposal will position me as a national leader in peri-hospitalization care of older adults and provide me the foundational knowledge, skills, and experiences necessary to design and test interventions to improve prescribing decisions