Optimizing Treatment of Older Adults with Hypertension: A Net Benefit Analysis of Falls Injury vs Cardiovascular Outcomes

优化老年高血压患者的治疗：跌倒损伤与心血管结果的净效益分析

• 批准号: 9250056
• 负责人: Lillian Chiang Min
• 金额: $ 32.88万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-09-01 至 2020-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9250056
• 关键词: Acute; Adherence; Adult; Affect; Age; Ambulatory Care; American; Benefits and Risks; Blood Pressure; Cardiac; Cardiovascular system; Caring; Cessation of life; Characteristics; Chronic; Clinical; Clinical Treatment; Comorbidity; Data; Data Set; Databases; Diabetes Mellitus; Disputes; Elderly; Electronic Health Record; Event; Fall injury; Fright; Future; Goals; Guidelines; Health; Health Status; Health and Retirement Study; Health system; Healthcare; Healthcare Systems; Heart failure; Hip Fractures; Hypertension; Hypotension; Individual; Injury; Interview; Joints; Link; Long-Term Care; Measures; Medical; Medicare; Medicare claim; Methods; Modeling; Myocardial Infarction; Outcome; Patients; Performance; Pharmaceutical Preparations; Population; Prevalence; Public Health; Recommendation; Reporting; Research; Risk; Risk Reduction; Severities; Statistical Methods; Stroke; Taxonomy; Testing; Variant; Veterans; Work; adverse outcome; aggressive therapy; arm; blood pressure reduction; blood pressure regulation; cardiovascular disorder risk; cardiovascular risk factor; clinical practice; common treatment; control trial; cost; disorder risk; epidemiology study; fall risk; falls; functional decline; health administration; hypertension control; improved; innovation; older patient; patient oriented; patient population; population survey; prevent; public health relevance; young adult

 DESCRIPTION (provided by applicant): Every year, one in 10 older people fall and sustain injury requiring medical care. Fall-related injury is the number one cause of accidental death in older Americans. However, fall injury is rarely considered as a outcome in controlled trials, which have traditionally focused on death and cardiovascular events. Until recently, we lacked methods of capturing fall-related injury in large healthcare databases. We will first use the Health and Retirement Study, a national study of older Americans, to develop a method of classifying severe fall injury in found in Medicare claims data across acute, ambulatory, and long-term care (Aim 1). Next, we will study how a national healthcare system, the Veterans Health Administration (VHA), delivers aggressive hypertension care (AHC) and whether AHC results in net benefit or harm due to cardiovascular events and severe fall-related injury. Hypertension is the single most common chronic condition in older adults. Medication treatment prevents important cardiovascular events (strokes, myocardial infarctions and heart failure), however also contributes to risk of falls. We do not fully understand the net benefits and harms among our oldest patients in clinical practice, especially after age 75 - those most prone to severe fall-injury. Thus, we aim to study the net harms and benefits associated with AHC, defined as low blood pressure (BP, <130/65 mmHg) and prescribed =3 BP medications. We have demonstrated that the VHA, a national leader in hypertension care, has used performance measures to improve care but increased rates of AHC - especially among older Veterans. The average BP for those with AHC was 114/58 mmHg - lower than the aggressive treatment arm in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. A study that captures AHC, achieved BP, and falls injury is needed. Such a study is not possible anywhere except in the VHA. In the VHA, we have carefully used sophisticated electronic databases to identify the older patients with AHC. We will study whether certain types of VHA facilities are more likely to deliver AHC to their older patients (Aim 2), then test whether AHC increases short-term risk of injurious falls (Aim 3A). Last, we will compare whether net harm results from AHC when considering both severe fall-related injury and cardiovascular events (Aim 3B). This research will inform which patients and facilities should be targeted for future efforts to reduce AHC. Innovation. This research includes innovative methods of using claims data across acute, ambulatory, and long term care data and cutting-edge statistical methods of modeling multiple outcomes to determine whether the harm of AHC outweighs the benefit of cardiovascular event reduction. Impact. Optimizing risks and benefits of approaches to hypertensive care is patient-centered and has implications for the broader health and care of older adults. At the patient level, health care information about low benefit and potential harm is critical to make informed decisions. At the population level, improved methods of optimizing treatment targets can apply to broader clinical tradeoffs in older patient populations.

 描述(申请人提供)：每年，每10名老年人中就有一人摔倒受伤，需要医疗护理。与跌倒相关的伤害是美国老年人意外死亡的头号原因。然而，在传统上关注死亡和心血管事件的对照试验中，坠落损伤很少被认为是一种结果。直到最近，我们还缺乏在大型医疗保健数据库中捕获与跌倒相关的伤害的方法。我们将首先使用健康和退休研究，这是一项针对美国老年人的全国性研究，以开发一种方法，对急性、门诊和长期护理(目标1)中的联邦医疗保险索赔数据中发现的严重跌倒伤害进行分类。接下来，我们将研究国家医疗体系--退伍军人健康管理局(VHA)如何提供积极的高血压护理(AHC)，以及AHC是否会因心血管事件和严重跌倒相关伤害而带来净收益或伤害。高血压是老年人最常见的一种慢性病。药物治疗可以预防重要的心血管事件(中风、心肌梗塞和心力衰竭)，但也会增加跌倒的风险。我们不完全了解临床实践中年龄最大的患者，特别是75岁以后--那些最容易发生严重跌伤的患者--的净收益和危害。因此，我们的目标是研究与AHC相关的净危害和益处，AHC被定义为低血压(BP，&lt；130/65 mm Hg)和处方=3BP的药物。我们已经证明，VHA是全国高血压护理的领先者，它使用绩效指标来改善护理，但增加了AHC的比率--特别是在老年退伍军人中。AHC患者的平均血压为114/58毫米汞-低于控制糖尿病心血管风险行动(ACCORD)试验中的积极治疗组。需要进行一项研究，了解AHC、血压和跌倒损伤。这样的研究在任何地方都是不可能的，除非在VHA。在VHA中，我们仔细使用了复杂的电子数据库来识别患有AHC的老年患者。我们将研究某些类型的VHA设施是否更有可能向老年患者提供AHC(目标2)，然后测试AHC是否会增加短期损伤性跌倒的风险(目标3A)。最后，我们将比较当同时考虑严重跌倒相关损伤和心血管事件时，AHC是否会导致净伤害(目标3B)。这项研究将告知哪些患者和设施应该成为未来减少AHC的目标。创新。这项研究包括使用急性、动态和长期护理数据中的索赔数据的创新方法，以及对多种结果进行建模的尖端统计方法，以确定AHC的危害是否大于减少心血管事件的好处。冲击力。优化高血压护理方法的风险和好处是以患者为中心的，并对老年人的更广泛的健康和护理具有影响。在患者层面上，有关低效益和潜在危害的卫生保健信息对于做出明智的决定至关重要。在人群水平上，优化治疗目标的改进方法可以适用于老年患者群体中更广泛的临床权衡。