Patient, Caregiver, and Regional Drivers of Potentially Inappropriate Medical Care for Dementia: Building the Foundation for State Dementia Policy

2010年，美国有470万人患有阿尔茨海默氏症，预计这一数字将接近 到2050年翻两番。虽然解决阿尔茨海默氏症和相关痴呆症的国家计划是努力 协调联邦、州和地方的努力，以应对这一日益增长的挑战，它明确表示，这是一个 国家计划而不是联邦计划“，剩下各州来决定如何最好地照顾这些患者 和他们的照顾者。由于随着年龄相关性痴呆的进展，认知和功能发生了变化， 这些患者和他们的照顾者的需求远远超出了医疗保健，需要从 各州。然而，社区居住的老年痴呆症患者最容易获得的护理是直接的。 医疗护理。此外，随着患者指导自己护理的能力下降，为他们提供的医疗保健 可能是由照顾者的需求和偏好驱动的。这些患者随后会经历：支离破碎 医疗保健，在多个门诊提供者之间协调不力；潜在的可预防的住院治疗； 以及滥用抗精神病药物，尽管有广泛的危害证据。由于国家主导的性质， 国家计划，关键是向各州提供这种不适当护理的关键预测指标，以帮助指导他们的 政策。我们将使用国家医疗保险数据，这是一项针对患有痴呆症的老年人及其照顾者的全国性调查， 以及一个由研究人员和国家政策专家组成的专家组，以完成以下目标：(1)确定 与向社区提供潜在不适当护理相关的患者和社区因素- 居住在与年龄相关的痴呆症成年人中，并建立准确的国家和州一级的估计 这就是关爱。我们将使用20%的横断面Medicare样本来确定以下所有50种药物的使用情况 国家：a)潜在可预防的住院治疗；b)零散的门诊护理；c)抗精神病药物的使用。(2) 确定其他患者的临床、功能、照顾者和护理的贡献 与地点的影响相关的潜在的不适当护理的特征。我们将使用国家 健康和老龄化趋势研究，全国照顾者调查，和地区卫生资源文件，以确定 与潜在不适当相关的患者、护理人员和区域医疗保健系统特征 为痴呆症患者提供医疗服务。(3)制定以证据为基础的痴呆症政策制定指南 我们将用它来采访州政府老化的政策官员。痴呆症研究人员和专家小组 州老龄化政策专家将应用我们的目标1和目标2的调查结果来制定基于证据的政策制定 框架，特别强调最危险的人群，我们将用它来指导采访 国家政策官员老龄化。我们工作的影响将是：1)确定患者、护理者和地区 导致老年性痴呆症患者可能不适当医疗的因素；2) 提供衡量未来系统级干预措施的基线；以及3)为 各州制定以证据为基础的痴呆症护理州计划。

4.7 million people in the United States had Alzheimer's disease in 2010, a number that is projected to nearly triple by 2050. While the National Plan to Address Alzheimer's Disease and Related Dementias is an effort to coordinate federal, state, and local efforts to confront this growing challenge, it explicitly states “this is a national plan and not a federal plan”, with individual states left to determine how to best care for these patients and their caregivers. Because of cognitive and functional changes as age-related dementia progresses, the needs of these patients and their caregivers extend far beyond healthcare, requiring a diverse response from states. However, the care most accessible to community-dwelling patients with age-related dementia is direct medical care. In addition, as a patient's ability to direct their own care declines, the healthcare provided to them may be driven by the needs and preferences of the caregiver. These patients then experience: fragmented medical care, poorly-coordinated across multiple outpatient providers; potentially preventable hospitalization; and overuse of antipsychotics despite extensive evidence of harms. Because of the state-led nature of the National Plan, it is critical to provide states with key predictors of this inappropriate care to help guide their policy. We will use national Medicare data, a national survey of older adults with dementia and their caregivers, and an Expert Panel of researchers and state policy experts to complete the following aims: (1) Identify patient and community factors associated with potentially inappropriate care delivered to community- dwelling adults with age-related dementia and establish accurate national and state-level estimates of this care. We will use a cross-sectional Medicare 20% sample to determine use of the following for all 50 states: a) potentially-preventable hospitalization; b) fragmented outpatient care; and c) antipsychotic use. (2) Determine the contribution of additional patient clinical, functional, caregiver, and caregiving characteristics to potentially inappropriate care relative to the effect of location. We will use the National Health and Aging Trends Study, National Survey of Caregivers, and Area Health Resource File to determine the patient, caregiver, and regional healthcare system characteristics associated with potentially inappropriate medical care for persons with dementia. (3) Develop an evidence-based policy making guide for dementia that we will use to interview state aging policy officials. An Expert Panel of dementia researchers and state aging policy experts will apply our Aim 1 and Aim 2 findings to develop an evidence-based policymaking framework with particular emphasis on populations most at risk, which we will use to guide interviews with state aging policy officials. The impact of our work will be to: 1) identify the patient, caregiver, and regional factors that contribute to potentially inappropriate medical care for patients with age-related dementia; 2) provide a baseline against which to measure future system-level interventions; and 3) develop a framework for states to develop evidence-based dementia care state plans.