Multimorbidity and Screening Colonoscopy: A Framework for Patients and Policy

多发病和筛查结肠镜检查：患者和政策框架

• 批准号: 7678587
• 负责人: Cary P. Gross
• 金额: $ 13.87万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2008
• 资助国家: 美国
• 起止时间: 2008-09-01 至 2011-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7678587
• 关键词: Multimorbidity; Screening; Colonoscopy; Framework; Patients

DESCRIPTION (provided by applicant): Many older persons have multiple, concurrent chronic illnesses, or "multimorbidity." At a time when scrutiny of quality of care is increasing, multimorbidity presents a unique challenge to the interpretation and application of evidence-based screening guidelines. For instance, screening colonoscopy is broadly conceived of as being effective and underused, with too few eligible patients undergoing the procedure. Yet the potential benefits of screening colonoscopy can vary substantially according to age and multimorbidity burden. Although it is intuitive that older, sicker patients have less to gain from screening colonoscopy, a framework based on population data is needed to determine how much older persons with varying burdens of multimorbidity could expect to benefit from undergoing screening colonoscopy. This framework would facilitate individualized decision-making at the bedside, inform the revision of screening guidelines, and allow focusing of quality of care initiatives on patients who are most likely to benefit from screening colonoscopy. Equally important is considering how targeting preventive strategies towards people with a lower burden of chronic illness could potentially adversely vulnerable populations, whose members carry a greater chronic illness burden. The objective of the proposed work is to further our understanding of how multimorbidity, sex, and age affect the risks and benefits of screening colonoscopy, with the intention of developing a framework that can be applied to other preventive health interventions. Population-based information about older cancer patients with colorectal cancer will be obtained from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. We will estimate (Aim 1), as a function of age, sex, and multimorbidity, the impact of screening colonoscopy on life expectancy, and the earliest time when the incremental benefits from screening colonoscopy exceed the incremental harms (i.e., the payoff time). After using a modeling approach to develop simple, transportable decision rules for determining which patients are likely or unlikely to benefit from a 1-time screening colonoscopy (Aim 2), Medicare claims data will be used to determine the population-level benefit that would accrue if colorectal cancer screening were more closely aligned with these decision rules (Aim 3). Finally, we will examine the effect of reallocating screening colonoscopies according to our calculated decision rules on vulnerable populations, including minority race and those with lower socioeconomic status, in terms of use of screening colonoscopy and over-all mortality (Aim 4). The resulting data will inform decision making at both the bedside and the health system level, by providing explicit decision rules as well as delineating the implications of implementing such rules for the over-all population, members of vulnerable populations, and individual patients.

描述（由申请人提供）：许多老年人同时患有多种慢性疾病，或“多重疾病”。在对保健质量的审查日益加强的时候，多病对基于证据的筛查指南的解释和应用提出了独特的挑战。例如，筛查结肠镜检查被广泛认为是有效的，但没有得到充分利用，接受该手术的合格患者太少。然而，结肠镜筛查的潜在益处可能因年龄和多重疾病负担而有很大差异。虽然人们直观地认为，年龄较大、病情较重的患者从筛查性结肠镜检查中获益较少，但需要一个基于人口数据的框架来确定患有多种疾病的不同负担的老年人从筛查性结肠镜检查中获益的程度。该框架将促进床边的个性化决策，为筛查指南的修订提供信息，并允许将护理质量的重点放在最有可能从筛查结肠镜检查中受益的患者身上。同样重要的是，考虑如何将预防战略的目标对准慢性疾病负担较轻的人，这可能对弱势群体产生不利影响，这些群体的成员背负着更大的慢性疾病负担。拟议工作的目的是进一步了解多病、性别和年龄如何影响筛查结肠镜检查的风险和益处，目的是建立一个可应用于其他预防性健康干预措施的框架。老年结直肠癌患者基于人群的信息将从相关的监测、流行病学和最终结果(SEER)-Medicare数据库中获得。我们将估计（目的1），作为年龄、性别和多病的函数，结肠镜筛查对预期寿命的影响，以及结肠镜筛查的增量收益超过增量危害的最早时间（即回报时间）。在使用建模方法制定简单、可移植的决策规则，以确定哪些患者可能或不可能从一次性结肠镜检查中获益（目标2）之后，医疗保险索赔数据将用于确定如果结直肠癌筛查更紧密地符合这些决策规则，将产生的人群水平的获益（目标3）。最后，我们将根据我们对弱势人群（包括少数民族和社会经济地位较低的人群）计算的决策规则，就结肠镜筛查的使用和总体死亡率而言，检查重新分配结肠镜筛查的影响（目标4）。由此产生的数据将通过提供明确的决策规则以及描述实施这些规则对全体人口、弱势群体成员和个别患者的影响，为床边和卫生系统层面的决策提供信息。