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Optimizing Chronic Disease Prevention and Management in Advanced Dementia

优化晚期痴呆症的慢性病预防和管理

基本信息

批准号：
8015841
负责人：
JENNIFER TJIA
金额：
$ 49.92万
依托单位：
UNIV OF MASSACHUSETTS MED SCH WORCESTER
依托单位国家：
美国
项目类别：
财政年份：
2010
资助国家：
美国
起止时间：
2010-09-30 至 2012-09-29
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/8015841
关键词：
Optimizing Chronic Disease Prevention Management

项目摘要

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.

描述（由申请人提供）：医疗保健研究和质量局邀请拨款申请，目的是了解不同策略在预防和管理多种慢性疾病患者的慢性疾病方面的比较价值。在本应用程序“优化老年痴呆症慢性病预防和管理”中，我们提出研究老年痴呆症患者中医学复杂人群的慢性疾病药物预防的有效性。美国160万居民中有一半以上患有痴呆症，晚期痴呆症患者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%的晚期痴呆症患者使用了不适合晚期痴呆症的药物，并且在这些患者生命的最后一周继续使用了近20%的药物。这些药物如降脂和骨质疏松药物可能与护理目标不一致，增加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。本R21的目标是发展基础设施，以系统地调查策略的有效性和安全性，以重新考虑NH居民晚期痴呆的慢性非痴呆疾病的药物治疗。我们描述了一系列研究中的第一项，评估了晚期痴呆药物的相对有效性，以便合理地优先考虑这一脆弱和研究不足的人群的治疗。特别关注的是评估NH晚期痴呆患者使用不当药物的患病率、成本和相关因素，以及评估该人群中使用和停用他汀类药物治疗心血管疾病的临床影响。研究将利用与联邦授权的NH居民评估数据相关的行政索赔数据，这些数据来自两个大人群：1)超过12,500名患有痴呆症的NH居民，他们在2005-2008年间接受了全国长期护理药房的处方服务；2) 5个州（明尼苏达州，马萨诸塞州，宾夕法尼亚州，加利福尼亚州和佛罗里达州）的NH居民，包括约95,000名在2006-2007年间使用医疗保险D部分药物福利的痴呆症NH居民。这些人群的数据来源包括：所有配发药物的药物索赔；居民人口统计;住院索赔;NH设施特点和死亡率。分析将采用技术来解决观察性研究中的选择偏差（倾向评分、比较组限制和自我控制的病例系列），以及纵向和集群数据的方法，以解释NHs内同一居民的重复处方。这些研究为评估处方策略及其对NH晚期痴呆居民的影响提供了分析策略，并为优化该人群的处方奠定了基础。