Optimizing prescribing decisions for hospitalized older adults with chronic conditions

项目摘要/摘要 美国每年有超过700万65岁及以上的成年人住院，其中三分之二患有多发性 慢性疾病。老年人通常会因更换慢性病药物而出院，例如 如高血压和糖尿病，这与他们住院的原因没有直接关系。在当前 实践中，既不是先前的慢性病控制，也不是关键的老年问题，如多病、多药联用或 认知似乎会影响出院处方的决定。迫切需要重新定位当前的 医院管理老年人慢性病的方法从数字驱动到患者- 以决策为中心的过程。治疗指南的设计并不是为了向 住院的老年人，他们更经常面临多病，在从急性疾病中恢复时，可能 面临短暂的认知和功能下降以及长期的预后变化，这些变化既影响风险，也影响 慢性病药物的好处。尽管已经做出了实质性的努力来改善排放 药物调节，很少关注理解临床医生改变慢性疾病的理由 不坚持改变的药物或患者理由，其中可能包括不良反应或不良反应 变革的沟通。我的长期目标是成为全国改善安全和安全的领导者 护理过渡期间老年人慢性病管理的质量。这样做的目的是 建议进行一项前瞻性队列研究，以解决目前临床医生的知识差距 出院时开出的慢性药物改变的理由和随后的患者结果。这部小说 信息将为临床决策框架的开发和试点测试提供信息，该框架将包括 住院老年人个性化出院处方决定的老年原则，重点是2 样本情况：高血压和糖尿病。在一支精湛的老龄化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)开展 长期服药出院老年人的前瞻性混合方法队列研究 评估临床医生做出用药改变的理由的变化，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 住院老年人个性化出院糖尿病和高血压处方决策的框架 成人3)进行先导性前测-后测试验，以了解是否提供临床决策框架工具 促进自我效能感，使处方决定个人化，并提高患者对 药物会有变化。这项提议将产生一种创新的老年学-知情的方法来治疗慢性 为住院的老年人提供处方决定的条件。提案的完成将使我成为 全国老年人住院期间护理的领先者，并为我提供基础知识，技能， 以及设计和测试干预措施以改进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