Optimizing Care for Older Adults through Thyroid Hormone Deprescribing

摘要/项目摘要 与年轻人相比，老年人甲状腺功能减退症的患病率高得不成比例。 与左旋甲状腺素（最广泛使用的合成甲状腺激素）一直是最重要的 在美国最常见的处方药。令人担忧的是，高达48%的65岁以上的老年人 10岁以上的人接受的甲状腺激素剂量过高，导致过度治疗。此外，甲状腺激素 治疗通常是针对不适当的适应症（误用）开始的，这也可能导致过度治疗。这是 特别是老年人，他们是人口增长最快的群体， 易受多种药物治疗的影响我们的团队和其他人进行的研究表明，甲状腺激素 过度治疗可导致严重的心血管和骨骼风险，并增加死亡率。尽管有潜力 患者伤害，~90%的患者继续终身甲状腺激素治疗。因此，在甲状腺的背景下， 激素过度治疗，有一个关键需要取消，这可以通过甲状腺激素， 剂量递减（在过度治疗的患者中）或甲状腺激素停药（在没有 适当的指示）。这项拟议的研究是第一个多中心试验，以评估一种新的循证适应 多层次干预，D-THIO（老年人甲状腺激素处方），包括基于证据的 给提供者的药物意见书，给患者的教育手册，并由临床冠军提供便利， 来支持老年人减少甲状腺激素的使用。我们将进行第一种混合效率- D-THIO与加强常规护理实施试验（美国甲状腺协会[ATA]提供者 简要指南，ATA患者手册）在3个研究中心（密歇根大学，亨利福特， 加州旧金山弗朗西斯科）的150名提供者（初级保健、内分泌学家、老年病学家、高级实践 提供者）和750名65岁以上的患者过度使用甲状腺激素。我们将随机1：1在 每个站点内的供应商级别。我们提出了三个具体目标：1）评估D-THIO对 提供者取消甲状腺激素处方，减少过度治疗和滥用甲状腺激素 通过EMR，2）评估D-THIO对提供者和患者知识和态度的有效性， 通过调查确定甲状腺激素处方，以及3）确定与D-THIO实施相关的因素 通过与关键利益相关者的试验后访谈，在不同的一般护理环境中进行。最终，我们的发现将 作为一个模式，取消不适当的药物治疗其他内分泌疾病和条件， 生化监测，并推进我们对老年人低价值护理的理解 在全国范围内。

Abstract/Project Summary Older adults have a disproportionately higher prevalence of hypothyroidism compared to their younger counterparts, with levothyroxine (the most widely used synthetic thyroid hormone) consistently one of the top most frequently prescribed medications in the United States. Alarmingly, up to 48% of older adults aged 65 years receive a thyroid hormone dose that is too high, resulting in overtreatment. In addition, thyroid hormone therapy is often initiated for inappropriate indications (misuse) which can also lead to overtreatment. This is especially concerning for older adults, who comprise the fastest growing demographic group and the most vulnerable to polypharmacy. Studies conducted by our team and others have demonstrated that thyroid hormone overtreatment can lead to significant cardiovascular and skeletal risks, and increased mortality. Despite potential patient harm, ~90% of patients continue lifelong thyroid hormone treatment. Thus, in the context of thyroid hormone overtreatment, there is a critical need to deprescribe, which can be achieved either via thyroid hormone dose de-escalation (in patients overtreated) or thyroid hormone discontinuation (in patients without an appropriate indication). The proposed study is the first multi-site trial to evaluate a novel evidence-based adapted multilevel intervention, D-THIO (Deprescribing Thyroid Hormone In Older Adults), consisting of evidence-based pharmaceutical opinion letters to providers, education brochures to patients and facilitated by clinical champions, to support thyroid hormone deprescribing in older adults. We will conduct a type 1 hybrid effectiveness- implementation trial of D-THIO vs. enhanced usual care (American Thyroid Association [ATA] provider abbreviated guidelines, ATA patient brochure) at 3 sites (University of Michigan, Henry Ford, University of California San Francisco) in 150 providers (primary care, endocrinologists, geriatricians, advance practice providers) and 750 of their patients 65 years overtreated with thyroid hormone. We will randomize 1:1 at the provider level within each site. We propose three specific aims: 1) to assess the effectiveness of D-THIO on thyroid hormone deprescribing by providers and on reducing overtreatment and misuse with thyroid hormone via EMR, 2) to assess the effectiveness of D-THIO on provider and patient knowledge and attitudes regarding thyroid hormone deprescribing via surveys, and 3) to identify factors related to the implementation of D-THIO across diverse general care settings via post-trial interviews with key stakeholders. Ultimately, our findings will serve as a model for deprescribing inappropriate medications for other endocrine conditions and conditions with biochemical monitoring, and advance our understanding of de-implementation of low-value care in older adults across the nation.