Frailty and Monitored Anesthesia Care for Cataract Surgery in Older Adults

项目摘要 绝大多数老年人接受白内障手术，术中一对一的监测和镇静 由麻醉师或护士麻醉师(也称为“监控麻醉护理”或“MAC”)实施。 MAC的支持者认为，白内障患者-其中许多人由于晚期白内障合并而虚弱 年龄、多发病和潜在视力损害--通常受益于密切的术中监测 是麻醉专业人士做的。然而，考虑到该程序的总体安全状况和预计的增加 随着美国人口老龄化，政策制定者、临床医生和支付者对白内障手术的需求提出了质疑 在美国是否应该继续常规使用MAC进行白内障手术。目前，存在着不充分的 预测哪些患者将面临最高伤害风险的证据，如果MAC作为一种 常规白内障手术的组成部分。这项拟议研究的基本原理是，确定 伤害风险最高的患者的特征有助于谨慎过渡到非MAC白内障 大多数患者在没有MAC的情况下可以安全地进行手术(并且不会受到伤害)。 中心假设是，仅对相对较小的高风险子集提供MAC是必要的 接受白内障手术的老年人。为了验证这一假设，拟议的研究计划将调查 三个目标。目标1将检查脆弱、MAC和术后不良事件发生率之间的关系 通过回顾分析白内障手术的医疗保险报销情况。目标2将阐明促进者和 应用眼科医生半结构化访谈研究无MAC白内障手术的障碍 其实践代表了一系列MAC利用率。目标3将对低风险老年人进行一项试点研究 接受白内障手术以确定非MAC镇静剂治疗白内障的可行性和可接受性 做手术。这些目标将创造基础知识来支持未来的研究，这些研究可以确定 对于低风险的老年人来说，作为常规白内障手术的一部分，MAC可以被安全地移除。这个 候选人是加州大学旧金山分校的麻醉师和卫生服务研究员。候选人、她的导师和 她的科学顾问制定了一项全面的职业发展计划，与 拟议研究的目的。该计划的关键要素包括培训和教学，以获得专业知识 具备以下领域的知识：1)老年学和老年学原理；2)生物统计学方法 高级因果推理；3)定性研究方法简介；4)实施科学 和可行性初步研究，以及5)与思想领袖接触的结构化职业发展 老年病学、卫生服务研究、眼科和麻醉学。这个职业发展奖将 帮助候选人实现成为全国老年围手术期卫生服务领导者的目标 在促进以证据为基础的、高价值的老年人手术和麻醉护理方面处于前沿的研究。 有了强大的机构承诺，候选人处于有利地位，可以实现研究独立。

Project Summary The vast majority of older adults undergo cataract surgery with 1-to-1 intraoperative monitoring and sedation administered by an anesthesiologist or nurse anesthetist (a.k.a., “monitored anesthesia care” or “MAC”). Proponents of MAC believe that cataract patients—many of whom are frail due to a combination of advanced age, multimorbidity and underlying visual impairment—generally benefit from close intraoperative monitoring by an anesthesia professional. However, given the procedure’s overall safety profile and the projected increase in cataract surgery demand as the US population ages, policymakers, clinicians, and payers have questioned whether the routine use of MAC for cataract surgery should continue in the US. Currently, there is inadequate evidence to predict which patients would be at highest risk for harm if MAC were to be removed as a component of routine cataract surgery. The rationale underlying the proposed research is that identifying the characteristics of patients at highest risk of harm could help facilitate a careful transition to non-MAC cataract surgery for the majority of patients who would be safe to proceed (and would not be harmed) without MAC. The central hypothesis is that the provision of MAC is only necessary for a relatively small subset of high-risk older adults undergoing cataract surgery. To test this hypothesis, the proposed research plan will investigate three aims. Aim 1 will examine the relationship between frailty, MAC, and the incidence of adverse events after cataract surgery through retrospective analysis of Medicare claims. Aim 2 will shed light on the facilitators and barriers for performing cataract surgery without MAC using semi-structured interviews of ophthalmologists whose practices represent a range of MAC utilization. Aim 3 will carry out a pilot study of low-risk older adults undergoing cataract surgery to determine feasibility and acceptability of non-MAC sedation for cataract surgery. These aims will create foundational knowledge to support future studies that can determine whether MAC can safely be removed as a component of routine cataract surgery in low-risk older adults. The Candidate is an anesthesiologist and health services researcher at UCSF. The Candidate, her mentors and her scientific advisors have developed a comprehensive career development plan that aligns well with the Aims of the proposed research. The key elements of this plan include training and didactics to obtain specialty knowledge in the following areas: 1) Principles of geriatrics and gerontology, 2) Biostatistical methods for advanced causal inference; 3) Introduction to qualitative research methodologies; 4) Implementation science and feasibility pilot studies, and 5) Structured career development with exposure to thought leaders in geriatrics, health services research, ophthalmology, and anesthesiology. This career development award will help the Candidate achieve her goal of becoming a national leader in geriatric perioperative health services research at the forefront of promoting evidence-based, high-value surgical and anesthetic care in older adults. With strong institutional commitment, the Candidate is well-positioned to attain research independence.