Optimizing Chronic Disease Prevention and Management in Advanced Dementia

描述（由申请人提供）：医疗保健研究和质量机构已邀请拨款申请，以了解不同策略在预防和管理患有多种慢性病的人的慢性病方面的比较价值。在这个应用程序中，“优化慢性病预防和管理中的晚期痴呆症”，我们建议研究药物预防慢性病的有效性在医疗复杂的人口的养老院（NH）居民与晚期痴呆症。超过一半的160万美国NHS居民患有痴呆症，而那些患有晚期痴呆症的人的预后与转移性乳腺癌或IV期心力衰竭相当。我们之前的工作表明，近40%的NH晚期痴呆症患者使用了不适合晚期痴呆症的药物，并且在生命的最后一周内，近20%的患者继续使用这些药物。这些药物（如降脂和骨质疏松症药物）可能与护理目标不一致，增加了药物不良事件和药物相互作用的风险，价格昂贵，并导致多种药物。由于缺乏对这一人群的药物有效性和停药安全性的研究，改善晚期痴呆症处方的努力受到阻碍。该R21的目标是开发基础设施，系统地研究策略的有效性和安全性，以重新考虑患有晚期痴呆症的NH居民的慢性非痴呆症疾病的药物治疗。我们描述了一系列研究中的第一项，评估了晚期痴呆症中可疑获益药物的比较有效性，以便合理地优先考虑对这一脆弱和研究不足的人群的治疗。一个特别的重点是评估的患病率，成本和相关因素使用药物不适当的NH居民与晚期痴呆症，并在评估的临床影响，使用和停用他汀类药物治疗心血管疾病在这一人群。研究将利用与来自2大人群的联邦授权的NH居民评估数据相关的行政索赔数据：1）2005-2008年期间接受全国长期护理药房处方服务的12，500多名患有痴呆症的NH居民; 2）5个州的NH居民（明尼苏达州、马萨诸塞州、宾夕法尼亚州、加州和佛罗里达），包括~95，2006-2007年期间使用Medicare Part D药物福利的000名患有痴呆症的NH居民。这些人群的数据来源包括：所有分发药物的药物索赔;居民人口统计学;住院索赔; NH设施特征和死亡率。分析将采用技术来解决观察性研究中的选择偏倚（倾向评分、对照组限制和自我对照病例系列），以及纵向和聚类数据的方法来解释NH内相同居民的重复处方。这些研究推进了评估处方策略及其对患有晚期痴呆症的NH居民的影响的分析策略，并为优化这一人群的处方奠定了基础。 公共卫生相关性：据估计，美国有180万人患有晚期痴呆症，无法识别家人，无法沟通，日常生活活动依赖身体。这些患者使用过于复杂的药物治疗方案，但没有充分的证据表明这样做会改善他们的生存或生活质量。由于在这一人群中不必要和不适当的药物使用增加了药物不良事件造成伤害的风险，并导致医疗费用上升，因此有必要进行比较有效性研究，通过检查这一脆弱和研究不足人群的药物有效性和停药安全性来改善处方。

DESCRIPTION (provided by applicant): The Agency for Healthcare Research and Quality has invited grant applications for the purpose of understanding the comparative value of different strategies in the prevention and management of chronic illness in persons with multiple chronic conditions. In this application, "Optimizing Chronic Disease Prevention and Management in Advanced Dementia", we propose to study the effectiveness of medication prophylaxis for chronic illness in the medically complex population of nursing home (NH) residents with advanced dementia. Over half of the 1.6 million residents of US NHs have dementia, and those with advanced dementia have a prognosis comparable to that of metastatic breast cancer or stage IV heart failure. Our prior work shows that medications inappropriate in advanced dementia are used by almost 40% of NH residents with advanced dementia, and are continued in almost 20% of these patients in the last week of life. These agents such as lipid-lowering and osteoporosis drugs may not be consistent with goals of care, increase the risk of adverse drug events and drug-drug interactions, are costly, and contribute to polypharmacy. Efforts to improve prescribing in advanced dementia are hampered by a lack of studies examining medication effectiveness and drug withdrawal safety in this population. The goal of this R21 is to develop the infrastructure to systematically investigate the effectiveness and safety of strategies to reconsider medications for chronic non-dementia illnesses in NH residents with advanced dementia. We describe the first in a series of studies evaluating the comparative effectiveness of medications of questionable benefit in advanced dementia, in order to rationally prioritize therapy for this vulnerable and understudied population. A particular focus is on the evaluation of the prevalence, cost, and factors associated with using medications inappropriate in NH residents with advanced dementia, and in evaluating the clinical impact of the use and discontinuation of statins for cardiovascular disease in this population. Studies will utilize administrative claims data linked to federally- mandated NH resident assessment data from 2 large populations: 1) over 12,500 NH residents with dementia who received prescription services from a nationwide long term care pharmacy between 2005-2008; and 2) NH residents of 5 states (Minnesota, Massachusetts, Pennsylvania, California and Florida), including ~95,000 NH residents with dementia who used Medicare Part D drug benefits between 2006-2007. Data sources for these populations include: drug claims for all dispensed medications; resident demographics; hospitalization claims; NH facility characteristics and mortality. Analyses will adapt techniques to address selection bias in observational studies (propensity scores, comparator group restriction, and self-controlled case-series), and methods for longitudinal and clustered data to account for repeat prescriptions in the same residents within NHs. These studies advance analytic strategies for evaluating prescribing strategies and their effects on NH residents with advanced dementia and lay the foundation for efforts to optimize prescribing in this population. PUBLIC HEALTH RELEVANCE: Project Narrative An estimated 1.8 million people in the United States are living with advanced dementia and are unable to recognize family, unable to communicate, and are physically dependent in activities of daily living. These patients use excessively complex medication regimens without good evidence that doing so will improve their survival or quality of life. Since unnecessary and inappropriate medication use in this population increases the risk of injury from adverse drug events and contributes to rising healthcare costs, comparative effectiveness studies are necessary to improve prescribing by examining medication effectiveness and drug withdrawal safety in this vulnerable and understudied population.