Optimizing surgical decision-making for nursing home residents undergoing surgery for bladder and bowel dysfunction

项目摘要： 我们对膀胱和肠道手术相关结果的理解存在着根本的差距。 功能障碍，这是疗养院居民中普遍存在的疾病。尽管有这些程序 由于风险相对较低，它们并非没有风险，特别是在功能和认知上已经存在的情况下 有限的队列。目前，关于这类结果的唯一可用信息来自于在 更年轻和更健康的人，他们缺乏重要的功能和认知结果， 对老年人有意义。我们的主要研究目标是改善对养老院的护理 通过为膀胱和肠道功能障碍的居民及其医疗保健提供者提供现实的 对这些疾病的手术治疗的风险和好处的预期。该计划的目标是 建议的研究是为了更好地了解这些手术的手术和功能结果 并为患者和他们的提供者提供一种预后工具，以帮助 手术决策过程。中心假设是，有大量和重要的 这些手术导致的即时和长期并发症，从高比率 手术发病率和死亡率(与社区居民对照相比)和较差的功能结果 通过日常生活活动、认知能力和特定的肠道和膀胱功能结果来衡量。这 假设将通过利用最小数据集(MDS)进行疗养院住院评估来检验 和医疗保险报销数据(住院患者和门诊患者)按以下三个具体目的：1)比较 短期(30天死亡率、手术并发症、住院时间、再入院)和长期(1年 死亡率和护理强度)疗养院居民与年龄、性别和 共病匹配的社区老年人接受膀胱和肠道的择期手术 功能障碍，2)确定功能状态、认知和膀胱和肠道的纵向变化 疗养院居民在膀胱和肠功能障碍择期手术后的功能 3)开发和内部验证疗养院居民考虑选择的预后工具 膀胱和肠功能障碍手术对手术发病率、死亡率和术后死亡率的预测 功能、认知和排便功能。这项研究具有创新性，因为它将测量和 将纵向功能和认知结果数据应用于外科手术的预后工具 为改善已经功能受损的人群的功能而实施的。拟议的研究 是重要的，因为没有关于这些常见情况的结果的信息 弱势群体。开发一种有助于这一决策过程的预测工具将有助于 将可能不成功、不必要甚至有害的程序的风险降至最低，同时促进 在更有可能获得福利的个人中使用这种程序。

PROJECT ABSTRACT: There is a fundamental gap in our understanding of outcomes related to surgery for bladder and bowel dysfunction, which are ubiquitous conditions among nursing home residents. Despite these procedures being relatively “low risk”, they are not without risk, particularly in an already functionally and cognitively limited cohort. Currently, the only available information on such outcomes are from studies conducted in younger and healthier individuals and they lack important functional and cognitive outcomes that are meaningful to older adults. Our overarching research objective is to improve care for nursing home residents with bladder and bowel dysfunction by providing them and their healthcare providers with realistic expectations about the risks and benefits of surgical treatment for these conditions. The objective for the proposed study is to better understand the surgical and functional outcomes of these procedures in the nursing home population and to provide patients and their providers with a prognostic tool to assist in the surgical decision-making process. The central hypothesis is that there are substantial and significant immediate and long-term complications resulting from these procedures, spanning from high rates of surgical morbidity and mortality (compared to community-dwelling controls) and poor functional outcomes measured by activities of daily living, cognition and specific bowel and bladder functional outcomes. This hypothesis will be tested by leveraging Minimum Data Set (MDS) for Nursing Home Resident Assessment and Medicare claims data (inpatient and outpatient) by the following three specific aims: 1) to compare short-term (30-day mortality, surgical complications, length of stay, readmission) and long-term (1-year mortality and intensity of care) surgical outcomes between nursing home residents and age-, sex- and comorbidity-matched community-dwelling older adults undergoing elective surgery for bladder and bowel dysfunction, 2) to determine longitudinal changes in functional status, cognition, and bladder and bowel function among nursing home residents following elective surgery for bladder and bowel dysfunction, and 3) to develop and internally validate a prognostic tool for nursing home residents considering elective surgery for bladder and bowel dysfunction to predict surgical morbidity, mortality and postoperative function, cognition and bladder and bowel function. This study is innovative because it will measure and apply longitudinal functional and cognitive outcomes data to a prognostic tool for surgical procedures performed to improve function among an already functionally impaired population. The proposed research is significant because there is no information about outcomes for these common conditions in this large and vulnerable population. Development of a prognostic tool to aid in this decision-making process will serve to minimize the risks of potentially unsuccessful, unnecessary and even harmful procedures, while promoting the use of such procedures among individuals who are more likely to receive benefit.