Multimorbidity and Screening Colonoscopy: A Framework for Patients and Policy

描述（由申请人提供）：许多老年人有多种并发慢性疾病，或“多发病”。“在对护理质量的审查日益增加的时候，多发病对循证筛查指南的解释和应用提出了独特的挑战。例如，筛查结肠镜检查被广泛认为是有效的和未充分使用的，太少的合格患者接受该程序。然而，筛查结肠镜检查的潜在益处可能因年龄和多发病负担而有很大差异。虽然这是直观的，老年人，病情较重的患者从筛查结肠镜检查中获益较少，需要一个基于人口数据的框架，以确定有多少老年人与不同的多重负担可以期望从筛查结肠镜检查中受益。该框架将促进床边的个性化决策，为筛查指南的修订提供信息，并允许将护理质量举措集中在最有可能从筛查结肠镜检查中受益的患者身上。同样重要的是，要考虑针对慢性病负担较轻的人群的预防战略如何可能对易受伤害的人群产生不利影响，因为这些人群的慢性病负担更重。这项工作的目的是进一步了解多因素、性别和年龄如何影响结肠镜筛查的风险和益处，目的是建立一个可应用于其他预防性健康干预措施的框架。关于老年结直肠癌患者的基于人群的信息将从相关的监测、流行病学和最终结果（SEER）-医疗保险数据库中获得。我们将估计（目标1），作为年龄，性别和多发病率的函数，筛查结肠镜检查对预期寿命的影响，以及筛查结肠镜检查的增量获益超过增量危害的最早时间（即，支付时间）。在使用建模方法开发简单，可移植的决策规则以确定哪些患者可能或不可能从1次筛查结肠镜检查中受益（目标2）之后，医疗保险索赔数据将用于确定如果结直肠癌筛查与这些决策规则更紧密地对齐，则将产生的人群水平的益处（目标3）。最后，我们将检查根据我们计算的决策规则重新分配筛查结肠镜检查对弱势人群的影响，包括少数民族和社会经济地位较低的人群，在使用筛查结肠镜检查和总体死亡率方面（目标4）。由此产生的数据将为床边和卫生系统层面的决策提供信息，提供明确的决策规则，并描述实施这些规则对所有人群、弱势群体成员和个体患者的影响。

DESCRIPTION (provided by applicant): Many older persons have multiple, concurrent chronic illnesses, or "multimorbidity." At a time when scrutiny of quality of care is increasing, multimorbidity presents a unique challenge to the interpretation and application of evidence-based screening guidelines. For instance, screening colonoscopy is broadly conceived of as being effective and underused, with too few eligible patients undergoing the procedure. Yet the potential benefits of screening colonoscopy can vary substantially according to age and multimorbidity burden. Although it is intuitive that older, sicker patients have less to gain from screening colonoscopy, a framework based on population data is needed to determine how much older persons with varying burdens of multimorbidity could expect to benefit from undergoing screening colonoscopy. This framework would facilitate individualized decision-making at the bedside, inform the revision of screening guidelines, and allow focusing of quality of care initiatives on patients who are most likely to benefit from screening colonoscopy. Equally important is considering how targeting preventive strategies towards people with a lower burden of chronic illness could potentially adversely vulnerable populations, whose members carry a greater chronic illness burden. The objective of the proposed work is to further our understanding of how multimorbidity, sex, and age affect the risks and benefits of screening colonoscopy, with the intention of developing a framework that can be applied to other preventive health interventions. Population-based information about older cancer patients with colorectal cancer will be obtained from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. We will estimate (Aim 1), as a function of age, sex, and multimorbidity, the impact of screening colonoscopy on life expectancy, and the earliest time when the incremental benefits from screening colonoscopy exceed the incremental harms (i.e., the payoff time). After using a modeling approach to develop simple, transportable decision rules for determining which patients are likely or unlikely to benefit from a 1-time screening colonoscopy (Aim 2), Medicare claims data will be used to determine the population-level benefit that would accrue if colorectal cancer screening were more closely aligned with these decision rules (Aim 3). Finally, we will examine the effect of reallocating screening colonoscopies according to our calculated decision rules on vulnerable populations, including minority race and those with lower socioeconomic status, in terms of use of screening colonoscopy and over-all mortality (Aim 4). The resulting data will inform decision making at both the bedside and the health system level, by providing explicit decision rules as well as delineating the implications of implementing such rules for the over-all population, members of vulnerable populations, and individual patients.