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

项目摘要/摘要 老年美国人在人口中所占的比例越来越大，对手术服务的需求也越来越大 与年轻的同龄人相比，他们遭受着不成比例的术后并发症负担。 有机会降低风险并改善对这一弱势群体的外科护理服务。 术前老年综合评估(PCGA)优化多种慢性疾病和因素 在常规的术前计划中通常被忽视，包括身体机能，多药，营养， 认知、心理健康和社会/环境支持；pCGA已被证明可以减少术后 发病率、死亡率和在各种外科专科的住院时间。尽管国家指南建议 PCGA的使用，缺乏实施的战略指导，使其仅限于少数几个学术中心。 系统工程和实施科学提供了独特的工具来可靠地提高这一点的有效利用 重要的干预措施。该提案的目标是使用基于系统工程的方法来定制和试点 测试以用户为中心的pCGA实施包--可适用于基于社区的实施包 医院正在为多地点实施试验做准备。这项工作将促进公平获得pCGA， 保持有效性，保护医疗资源，防止可避免的发病率和死亡率。 这一目标与国家老龄研究所的战略愿景C3一致，即支持 行为干预以行为和社会科学的基本原理为基础，并着眼于 真实世界的实施，与NIH阶段模型一致。 我的长期目标是通过跨学科研究改善老年人的外科护理，促进 实施和传播有效的、以证据为基础、以病人为导向的干预措施。这份5年期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、临床试验和老龄化研究。以我在外科健康服务方面的深厚背景 研究，我很有能力进行这个项目，并在支持下过渡到研究独立 在一家拥有卓越研究环境的机构中，拥有一支专家导师团队。 拟议的研究目标是：1)绘制pCGA过程图，并确定基于系统的障碍和促进者 在接受腹部大手术的老年人中使用2)共同设计一个实施包，以 PCGA适用于在(2a)a接受大手术的老年患者的不同人群 大型学术医院和(2)附属社区站点，以及3)测试和改进pCGA实施 为未来的随机对照实施有效性试验做准备的一揽子计划。完工后 对于这个项目，我将有一个可适应的，以用户为中心的初步试点pCGA实施包 关于执行情况和效果的数据，这些数据将作为R01提案的基础，以进行多项 PCGA在接受腹部手术的老年人中的现场混合实施-有效性临床试验。

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.