Enhanced Quality in Primary Care for Elders with Diabetes and Dementia (EQUIPED-ADRD)

项目总结 超过1100万65岁的美国人患有糖尿病(DM)，这是一种需要自我调节的典型慢性病。 管理层。高达30%的老年人患有糖尿病和阿尔茨海默病及相关痴呆症 患有糖尿病(ADRD)的老年人患ADRD的风险可能高达两倍。照顾者 同时患有DM-ADRD的患者有许多未得到满足的需求，对照顾者的能力产生了不利影响 管理好这些条件。此外，缺乏证据表明是什么构成了这些项目的最佳DM管理 患者，特别是那些年龄更大的患者(≥75岁)，进一步加剧了管理的挑战 从患者和医疗提供者的角度来看，这是一种慢性且往往并存的疾病。由于缺乏 在决策指导方面，初级保健提供者目前没有能力直接提供保健以取得最佳结果。 这项研究的目标是为老年糖尿病患者开发和测试质量改进计划。 ADRD，在一个大型、多样化的医疗保健中使用务实的随机对照试验(RCT)和混合方法 系统。这将为DM-ADRD患者的医疗管理提供协商一致的决策指导， PCP工作流程增强，包括使用小组管理器和电子健康记录(EHR) 决策支持/反馈和PCP协作学习。为了进行这项研究， 老年糖尿病初级护理-ADRD“(装备-ADRD)，我们将使用R21/R33机制。这个 R21在第一年将开发务实试验所需的关键资源，如提供商决策 基于现有证据的指导、试验设计和评估方法、适当的医疗保健系统 行政/电子健康记录支持，并将测试干预的可行性。R33将实施更大的务实 通过对12个最大的初级保健诊所进行集群随机化，在大型医疗系统中进行试验 有大约60名提供者和600多名确诊为糖尿病和ADRD的患者。它将测试以下假设： 基于明确的糖尿病医疗管理标准的ADRD患者的护理将：h1)改善患者 症状和生活质量，同时保持预期的临床结果；H2)减少患者和照顾者 根据患者/护理者的偏好管理负担和提高护理质量；H3)(次要) 减少专科、急诊科和医院使用率。我们将从EHR、Medicare和Medicaid收集数据 保险索赔、护理者调查和定性访谈以及临床医生访谈。 如果这项临床试验表明，接受这种增强护理质量的患者和家庭照顾者 计划实现糖尿病护理的既定目标，同时减少与痴呆症相关的症状，减少 护理人员的负担和压力，以及更少的DM相关不良事件，潜在地可以避免和成本高昂的利用 也可能会减少。然后，这种最佳实践方法可以广泛传播到其他临床实践。

PROJECT SUMMARY Over 11 million Americans who are ≥65 years have Diabetes (DM), a prototypic chronic disease requiring self- management. Up to 30% of older adults have co-occurring DM and Alzheimer's disease and related dementia (ADRD) and older people with DM may have as much as a two-fold risk of developing ADRD. Caregivers of patients with co-occurring DM-ADRD have many unmet needs, adversely affecting caregivers' ability to manage these conditions. Moreover, a lack evidence for what constitutes optimal DM management for these patients, particularly those of more advanced age (≥ 75 years), further compounds the challenge of managing this chronic and often comorbid disease from both the patient and medical provider perspective. With a lack of decisional guidance, primary care providers are currently ill equipped to direct care to achieve best outcomes. The goal of this research is to develop and test a quality improvement program for older patients with DM- ADRD, using a pragmatic randomized controlled trial (RCT) and mixed methods in a large, diverse healthcare system. This will feature consensus decisional guidance for the medical management of DM-ADRD patients, PCP workflow enhancements including use of a panel manager and the electronic health record (EHR) for decision support/feedback, and PCP collaborative learning. To conduct this study, “Enhanced Quality In Primary care for Elders with Diabetes-ADRD” (EQUIPED-ADRD), we will use the R21/R33 mechanism. The R21 in the first year will develop key resources needed for the pragmatic trial, such as provider decisional guidance based on current evidence, trial design and evaluation methodology, appropriate healthcare system administrative / EHR support, and will test intervention feasibility. The R33 will implement the larger pragmatic trial in a large healthcare system through cluster randomization of the 12 largest primary care practice sites with ~60 providers and over 600 patients with diagnosed DM and ADRD. It will test hypotheses about whether care based on explicit standards for DM medical management for people with ADRD will: H1) Improve patient symptoms and quality of life while maintaining expected clinical outcomes; H2) decrease patient and caregiver management burden and improve care quality based on patient/caregiver preferences; H3) (secondary) decrease specialty, ED and hospital utilization. We will gather data from the EHR, Medicare and Medicaid insurance claims, caregiver surveys and qualitative interviews, and clinician interviews. If this clinical trial demonstrates that patients and family caregivers who receive this enhanced care quality program achieve established goals for diabetic care in addition to fewer dementia-related symptoms, less caregiver burden and stress, and fewer DM-related adverse events, potentially avoidable and costly utilization may also decrease. This best practice approach could then be widely disseminated to other clinical practices.