Older Adult Safety in Surgery (OASIS)

简介(由申请人提供)：我是波士顿大学医学中心医院医学部的一名教员，在医院医学会的赞助下寻求GEMSSTAR R03奖，该学会正在赞助T·富兰克林·威廉姆斯奖。这些奖项将使我能够过渡到老龄化研究中的独立医院调查员。这项题为“老年人手术安全(OASIS)”的提案侧重于通过使用计算机疾病模拟模型衡量与健康相关的长期生活质量、存活率和成本，在接受手术的单一和共生合并症的老年人中确定最佳的围手术期损伤预防策略。医疗损伤在大手术后很常见，并不成比例地影响患有合并症的老年人。该提案使用全髋关节和膝关节置换术后静脉血栓栓塞症(VTE)预防作为一种方法的第一个案例，该方法可复制到许多其他安全目标。美国胸科医师学会建议在这种情况下只进行高效预防。包括磺达肝素和LMWH在内的高效力药物在降低VTE发生率方面非常有效，但对这些方案增加出血率的担忧减缓了它们的广泛采用，特别是在老年人中。选择预防医疗损害的最佳干预措施通常涉及到权衡其风险、收益和成本。在大多数手术中，这些都没有得到仔细的研究，特别是对于患有合并症和共病的老年人。在这项提案中，我将使用计算机疾病模拟来整合已发表的关于高效预防有效性的随机对照试验的数据、关于VTE背景风险的队列数据以及来自联邦医疗保险报销统计的成本，以预测与各种预防策略相关的长期结果。然后，我将使用退伍军人事务部数据的回归分析来衡量患有普遍并存的老年人亚群中VTE和出血的相对风险，并使用模拟模型预测这些亚群的长期结果。如果关于高效性预防的价值的结论在亚群中发生变化，概述的方法将代表着对老年手术患者围手术期评估的重大创新。

DESCRIPTION (provided by applicant): I am a faculty member in the Hospital Medicine Unit at Boston University Medical Center who seeks the GEMSSTAR R03 Award under the auspices of the Society of Hospital Medicine which is sponsoring a companion T. Franklin Williams award. These awards will enable me to transition into an independent hospitalist investigator in aging research. The proposal, entitled "Older Adult Safety in Surgery (OASIS)" focuses on identifying optimal perioperative injury prevention strategies in older adults with a single and co-occurring comorbidities undergoing surgery by measuring their associated long term health related quality of life, survival, and costs using a computer disease simulation model. Medical injury is common after major surgery and disproportionately affects older adults with comorbidities. The proposal uses venous thromboembolism (VTE) prophylaxis after total hip and knee replacement as a first case example of a method which may be replicated for numerous other safety targets. The American College of Chest Physicians recommends exclusively high potency prophylaxis in this setting. High potency agents including fondaparinux and LMWH are highly effective in reducing the incidence of VTE but concerns about increased rates of bleeding with these regimens have slowed their widespread adoption especially in older adults. Selecting the optimal intervention to prevent medical injury usually involves balancing its risks, benefits, and costs. These have not been carefully studied for most procedures, particularly for older adults with comorbidities and co-occurring comorbidities. In this proposal, I will use computer disease simulation to integrate data from published randomized controlled trials about the efficacy of high potency prophylaxis, cohort data about the background risk of VTE, and cost from Medicare reimbursement statistics to project long term outcomes related to various prophylaxis strategies. Then, I will measure the relative risk of VTE and bleeding in subpopulations of older adults with prevalent comorbidities using regression analyses of Veterans Affairs data and project long term outcomes with the simulation model in these subpopulations. If the conclusions about the value of high potency prophylaxis changes in the subpopulations, the method outlined would represent a major innovation in the perioperative assessment of older adult surgical patient.