Evaluation of treatment patterns and prescription medication use among older adults with late-onset rheumatoid arthritis

项目摘要/摘要 类风湿性关节炎(RA)是一种慢性、衰弱和代价高昂的疾病，对老年人的影响不成比例。 疾病修饰性抗风湿药物(DMARDS)改善了RA的预后，近年来，治疗 范式已演变为促进DMARD的早期启动、升级和组合。然而，老年人 由于多种药物和多种疾病的问题，不太可能接受积极的治疗。老年人 晚发性RA(LORA)具有更高的疾病活动性、更多的放射学进展和更大的 功能衰退。因此，侵袭性较低的治疗引起了更大的担忧，即更差的结果和更大 患有LORA的老年人的残疾程度。除了实现疾病缓解外，疼痛控制也是一种 类风湿关节炎治疗的重要目标和处方药，包括非类固醇类药物，糖皮质激素和 阿片类药物是类风湿性关节炎患者常用的药物。然而，这些处方药通常是 被认为不适合老年人使用，因为相关的不良反应，如跌倒的风险， 骨折和骨质疏松症。此外，老年人对以下常见不良影响的耐受性更有限 而且更容易产生多药联用的相加甚至倍增的风险，使情况进一步复杂化 医学上复杂的老年类风湿性关节炎的护理。关于使用DMARDS进行LORA新诊断的信息， 而对其他处方药使用的潜在无意依赖是很少的，因为老年人通常 排除在随机对照试验之外。这在我们的理解中留下了一个空白，即面对 多药联用和多病并存，治疗模式的变化对医学复杂的老年人的预后影响 成人类风湿性关节炎。在缺乏试验数据的情况下，利用行政数据的大型观察性研究 在填补这种类型的科学知识空白方面发挥重要作用，并允许了解 常规护理中的治疗选择。在这项使用联邦医疗保险数据的回溯性队列研究中，我们建议实现2 目标。在目标1中，我们将描述DMRADs和其他处方的模式和与之相关的因素 新诊断为LORA的老年人的用药情况。在目标2中，我们将比较结果 与LORA新病例的治疗和启动DMARD的时机有关。这项提议提供了一个现实世界 以及对接受DMARDS治疗的老年RA患者接受护理的人群水平的研究。初步数据和 从这项研究中获得的分析将成为未来职业发展奖的基础，以解决独特的 与为老年人开出高风险药物有关的挑战。来自GEMSSTAR奖的支持， 随着我迈向专注于独立研究人员的职业生涯，指导和培训将是无价的 关于设计、实施和评估护理模式以提高老年患者的护理质量 风湿病。

PROJECT SUMMARY / ABSTRACT Rheumatoid arthritis (RA) is a chronic, debilitating and costly disease that disproportionally affects older adults. Disease modifying antirheumatic drugs (DMARDs) improve outcomes of RA and, in recent years, the treatment paradigm has evolved to promote early initiation, escalation, and combination of DMARDs. And yet, older adults are less likely to receive aggressive treatment due to issues of polypharmacy and multimorbidity. Older adults with late-onset RA (LORA) experience higher disease activity, more radiographic progression, and greater functional decline. Thus, less aggressive treatment raises greater concerns for poorer outcomes and greater levels of disability among older adults with LORA. In addition to achieving disease remission, pain control is an important goal in the treatment of RA and prescription medications including NSAIDS, glucocorticoids and opioids are in common use among patients with RA. However, these prescription medications are generally considered inappropriate for use in older adults because of associated adverse effects such as risk of falls, fractures and osteoporosis. Moreover, older adults have more limited tolerance to common adverse effects of medications and are more prone to the additive or even multiplicative risk of polypharmacy, further complicating the care of medically complex older adults with RA. Information on use of DMARDs for new diagnosis of LORA, and potential unintentional reliance on other prescription medication use is scarce because older adults are often excluded from randomized controlled trials. This leaves a gap in our understanding of how, in the face of polypharmacy and multimorbidity, variation in patterns of treatment impact outcomes for medically complex older adults with RA. In the absence of trial data, large observational studies that leverage administrative data serve an important role in filling this type of scientific knowledge gap and also allow for understanding drivers of treatment choices in usual care. In this retrospective cohort study using Medicare data we propose to achieve 2 aims. In Aim 1, we will characterize patterns of and factors associated with DMRADs and other prescription medication use among older adults with a new diagnosis of LORA. And in Aim 2 we will compare outcomes related to treatment and timing of DMARD-initiation for new cases of LORA. This proposal provides a real-world and population-level study of the care received by older RA patients treated with DMARDs. Preliminary data and analyses obtained from this study will form the basis of future career development awards to address unique challenges related to prescribing high risk medications for older adults. Support from the GEMSSTAR award, mentorship, and training will be invaluable as I progress towards a career as an independent researcher focused on the design, implementation and evaluation of care models to improve quality of care in older patients with rheumatic diseases.