Optimizing treatment for nursing home residents with acute cholecystitis

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Project Summary/Abstract Acute cholecystitis - infection of the gallbladder - is one of the most common gastrointestinal conditions in the United States. Removal of the gallbladder (cholecystectomy) is the only definitive treatment for acute cholecystitis. More than a third of patients with acute cholecystitis who do not undergo surgery will experience gallstone related complications within 2 years of initial diagnosis. For this reason, cholecystectomy at the time of initial episode is considered the standard of care. Whether the risks of surgery are lower than the burdens of recurrent disease in patients with limited life-expectancy is unclear. Surgical decision-making for elder nursing home residents is challenging. Our overarching research objective is to improve care for nursing home residents by providing them and their health care providers realistic information about risks and benefits of treatment for common surgical diseases. For some conditions that are usually treated surgically, the risks of surgery for nursing home residents may outweigh the burdens of future disease complications that may never occur during their remaining lifetime. [Nonsurgical] therapies such as percutaneous gallbladder drainage or antibiotic therapy alone may be more appropriate. The objective of the proposed study is to better understand the use and outcomes of surgery and [nonsurgical] therapy to treat acute cholecystitis in elder nursing home residents. To inform nursing home residents and their health care providers about risks and benefits of different treatment strategies our project has three specific aims: [1) To evaluate current treatments for acute cholecystitis among nursing home residents and determine resident and provider characteristics associated with the use of cholecystectomy and [nonsurgical] treatment, 2) to identify determinants of short term outcomes after surgery and [nonsurgical] treatment among nursing home residents with acute cholecystitis and compare the outcomes of residents undergoing surgical v nonsurgical treatment and 3) to determine the association between resident and provider characteristics and longitudinal functional outcomes, survival, and recurrent gallbladder disease after initial treatment for acute cholecystitis and compare longitudinal outcomes of residents undergoing surgical and nonsurgical treatment.] The approach is innovative because, in addition to comorbidity, we will evaluate the impact of cognitive and functional status - important and powerful predictors of life expectancy - on treatment choice and outcomes for acute cholecystitis in the entire nursing home population age 65 and older in the United States. This study is significant because currently there is no information about treatment and outcomes for this common disease in this large and vulnerable population. For individuals with limited life expectancy, determining the individualized treatment that alleviates suffering and best maintain function is essential. Better knowledge of the safety and effectiveness of alternative treatment strategies in subgroups of nursing home residents will minimize the harms of both undertreatment and overtreatment of this common disease.