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 与之相对应的是，左旋甲状腺素(最广泛使用的合成甲状腺激素)一直位居榜首 在美国最常用的处方药。令人担忧的是，高达48%的65岁的老年人 每年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 尤其是老年人，他们构成了增长最快的人口群体，也是 容易受到多药联用的影响。我们团队和其他人进行的研究表明，甲状腺激素 过度治疗可能导致严重的心血管和骨骼风险，并增加死亡率。尽管有潜力 对患者有害的，~90%的患者继续终生接受甲状腺激素治疗。因此，在甲状腺的背景下 激素过度治疗，迫切需要停药，这可以通过甲状腺激素来实现 剂量降低(在过度治疗的患者中)或甲状腺激素停止(在没有 适当的指示)。这项拟议的研究是第一次多点试验，以评估一种新的基于证据的适应 多层次干预，D-硫代(老年人停用甲状腺激素)，由循证研究组成 给提供者的药物意见书，给患者的教育手册，以及临床冠军的协助， 以支持老年人停用甲状腺激素。我们将进行第一类混合效能- D-硫代与增强型普通护理的实施试验(美国甲状腺协会[ATA]提供者 简化指南，ATA患者手册)在3个地点(密歇根大学、亨利·福特大学、密歇根大学 加利福尼亚州旧金山)在150个提供者(初级保健、内分泌科医生、老年医生、高级实践 他们的患者中有750人65岁，甲状腺激素过度治疗。我们将以1：1的比例随机化 每个站点内的提供商级别。我们提出了三个具体目标：1)评估D-硫代巴比妥钠的疗效 提供方停用甲状腺激素与减少甲状腺激素的过度使用和滥用 通过EMR，2)评估D-thio对提供者和患者的知识和态度的有效性 通过调查停用甲状腺激素，以及3)确定实施D-硫代的相关因素 通过对关键利益攸关方的试验后访谈，跨越不同的一般保健环境。最终，我们的发现将 作为对其他内分泌疾病和有以下情况的不适当药物停药的典范 生化监测，促进我们对老年人取消低价值护理的理解 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.