Preparing older adults for major abdominal surgery: a systems engineering approach to implement preoperative comprehensive geriatric assessments

项目概要/摘要 老年美国人是一个不断增长的人口部分，对手术服务的需求不断增加， 与年轻人相比，他们承受着不成比例的术后并发症负担。 有机会降低风险，改善对这一弱势群体的外科护理。 术前综合老年评估（pCGA）优化多种慢性疾病和因素 在常规术前计划中通常被忽视，包括身体功能，多种药物，营养， 认知、心理健康和社会/环境支持; pCGA已被证明可降低术后 发病率，死亡率和住院时间在各种外科专业。尽管国家指导方针建议 pCGA的使用，缺乏实施的战略指导，限制了它的吸收到几个学术中心。 系统工程和实施科学提供了独特的工具，以可靠地提高有效利用这一 重要干预。该提案的目标是使用基于系统的工程方法来定制和试点 测试以用户为中心的pCGA实施包-一个可以适应基于社区的 准备进行多中心实施试验的医院。这项工作将促进公平获得pCGA， 保持有效性，保护卫生保健资源，预防可避免的发病率和死亡率。 这一目标与国家老龄问题研究所的战略愿景C3相一致，即“支持 基于基本行为和社会科学原则的行为干预， 真实世界的实现，符合NIH阶段模型。 我的长期目标是通过跨学科研究来改善老年人的外科护理， 实施和传播有效、循证、面向患者的干预措施。5年K23 建议将为我提供指导的研究经验和实施科学的正式培训， 系统工程、临床试验和衰老研究。凭借我在外科健康服务方面的深厚背景 研究，我很好地定位进行这个项目，并过渡到研究独立，与支持 在一个拥有杰出研究环境的机构中，拥有一支专家导师团队。 本研究的主要目的是：1）绘制pCGA过程图，并识别基于系统的障碍和促进因素 2）共同设计一个实施包， pCGA适用于在（2a）a接受腹部大手术的老年患者的不同人群 大型学术医院和（2b）附属社区网站，以及3）测试和完善pCGA实施 为将来的随机对照实施有效性试验做准备。完成后 在这个项目中，我将有一个适应性强，以用户为中心的实施包pCGA与初步试点 关于实施和有效性的数据，这将作为R 01建议的基础， pCGA在接受腹部手术的老年人中的现场混合实施效果临床试验。

PROJECT SUMMARY / ABSTRACT Older Americans are a growing segment of the population with an increasing need for surgical services, and they suffer a disproportionate burden of postoperative complications compared to their younger counterparts. There are opportunities to reduce risk and improve surgical care delivery for this vulnerable population. Preoperative comprehensive geriatric assessment (pCGA) optimizes multiple chronic conditions and factors commonly overlooked in routine preoperative planning, including physical function, polypharmacy, nutrition, cognition, mental health, and social/environmental support; pCGA has been shown to decrease postoperative morbidity, mortality and length of stay in a variety of surgical specialties. Although national guidelines recommend the use of pCGA, a paucity of strategic guidance for implementation limits its uptake to a few academic centers. Systems-engineering and implementation science offer unique tools to reliably improve effective use of this important intervention. The goal of this proposal is to use systems-based engineering methods to tailor and pilot test a user-centered implementation package for the pCGA – one that can be adapted to community-based hospitals in preparation for a multi-site implementation trial. This work will promote equitable access to the pCGA, preserving effectiveness, protecting healthcare resources, and preventing avoidable morbidity and mortality. This goal aligns with the National Institute on Aging’s strategic vision C3 to “Support the development of behavioral interventions based on principles of basic behavioral and social science and designed with an eye to real-world implementation, in line with the NIH Stage Model.” My long-term goal is to improve surgical care for older adults through transdisciplinary research that promotes implementation and dissemination of effective, evidence-based, patient-oriented interventions. This 5-year K23 proposal will provide me with mentored research experience and formal training in implementation science, systems-engineering, clinical trials and aging research. With my strong background in surgical health services research, I am well positioned to conduct this project and transition to research independence, with the support of a team of expert mentors at an institution with an outstanding research environment. The proposed research aims are to: 1) Map the pCGA process and identify system-based barriers and facilitators to its use among older adults undergoing major abdominal surgery 2) Co-design an implementation package for the pCGA applicable to a diverse population of older patients undergoing major abdominal surgery at (2a) a large academic hospital and (2b) an affiliate community site, and 3) Test and refine the pCGA implementation package in preparation for a future randomized controlled implementation-effectiveness trial. Upon completion of this project, I will have an adaptable, user-centered implementation package for pCGA with preliminary pilot data on implementation and effectiveness, which will serve as the basis for an R01 proposal to conduct a multi- site hybrid implementation-effectiveness clinical trial of the pCGA in older adults undergoing abdominal surgery.