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

项目概要/摘要 美国老年人口数量不断增长，对外科服务的需求不断增加，并且 与年轻的同行相比，她们承受着不成比例的术后并发症负担。 有机会降低风险并改善这一弱势群体的外科护理服务。 术前综合老年评估 (pCGA) 可优化多种慢性病和因素 在常规术前计划中经常被忽视，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 已被证明可在术后降低 各种外科专业的发病率、死亡率和住院时间。尽管国家指南建议 pCGA 的使用以及缺乏实施战略指导限制了其在少数学术中心的采用。 系统工程和实施科学提供了独特的工具来可靠地提高对此的有效利用 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 测试一个以用户为中心的 pCGA 实施包——一个可以适应基于社区的实施包 医院正在准备进行多地点实施试验。这项工作将促进公平获得 pCGA， 保持有效性、保护医疗资源并预防可避免的发病率和死亡率。 这一目标与国家老龄化研究所的战略愿景 C3 一致，即“支持 基于基本行为和社会科学原理的行为干预措施，旨在 现实世界的实施，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 实施和传播有效的、基于证据的、以患者为导向的干预措施。这5年K23 提案将为我提供指导研究经验和实施科学方面的正式培训， 系统工程、临床试验和衰老研究。凭借我在外科医疗服务方面的深厚背景 研究，我有能力开展这个项目并过渡到研究独立性，并得到支持 拥有优秀研究环境的机构的专家导师团队。 拟议的研究目标是： 1) 绘制 pCGA 流程并确定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 接受腹部大手术的不同老年患者群体 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 为未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，我将为 pCGA 提供一个适应性强、以用户为中心的实施包，并进行初步试点 有关实施和有效性的数据，这将作为 R01 提案的基础，以开展多方面的研究 pCGA 在接受腹部手术的老年人中进行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.