Optimizing prescribing decisions for hospitalized older adults with chronic conditions

项目总结/摘要 在美国，每年有超过700万65岁及以上的成年人住院，其中三分之二的人患有多种疾病。 慢性病老年人出院时经常会改变慢性病的药物治疗， 如高血压和糖尿病，这与他们住院的原因没有直接关系。当前 实践中，既没有先前的慢性病控制，也没有关键的老年问题，如多药，多药，或 认知似乎影响出院处方决定。迫切需要重新调整当前的 老年人慢性病的医院管理方法，从数字驱动到患者- 集中决策过程。治疗指南的设计并不是为了告知决策， 住院的老年人，他们更经常面临多重死亡，在从急性疾病中恢复时， 面临短暂的认知和功能下降以及影响风险和预后的长期变化， 慢性病药物的好处。尽管已经做出了很大的努力来改善排放 药物协调，很少关注了解临床医生改变慢性 药物或患者对变化不持续的理由，可能包括ADE或不良 沟通变化。我的长期目标是成为提高安全性的国家领导者， 在护理过渡期间，老年人慢性病管理的质量。这一目标 建议进行前瞻性队列研究，以解决临床医生目前的知识差距 出院时处方的慢性药物变更的依据和后续患者结局。这本小说 信息将告知临床决策框架的开发和试点测试，该框架将包括 老年医学原则，为住院老年人制定个性化的出院处方决定，重点是2 典型病症：高血压和糖尿病。在一个一流的衰老研究专家团队的指导下， 医院医学、药物流行病学和以临床医生为中心的干预发展，我将：1）进行一次 对出院后长期服药的老年人进行的前瞻性混合方法队列研究 评估临床医生改变用药的原因，老年人对 变化，以及变化后患者报告的结果; 2）制定和完善临床决策 住院老年人出院糖尿病和高血压处方决策的个体化框架 3）进行一项试验性的前测-后测试验，以了解是否提供临床决策框架工具， 促进自我效能，以个性化处方决策，并提高患者对 药物变化。该提案将为慢性病患者提供一种创新的老年学方法 条件处方决定住院老年人。完成提案将使我成为 在老年人的围住院期护理的国家领导者，并为我提供基础知识，技能， 以及设计和测试干预措施以改善处方决策所需的经验

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