Opioid use in post-acute hip fracture care: prescribing patterns, effectiveness, and safety

项目摘要 在急性后护理期间，老年人的疼痛管理比其他任何时候都更重要 髋部骨折住院治疗后。疼痛控制可以积极影响功能，帮助避免不良后果 如精神错乱，特别是在阿尔茨海默病和相关痴呆(ADRD)患者中。每年， 超过30万美国老年人出院，在急性后熟练护理设施接受康复治疗 髋部骨折后的SNFS，使SNFS成为研究止痛药处方实践及其影响的关键场所 在骨折之后。髋部骨折后的疼痛通常没有得到充分的治疗，而且没有证据支持。 指导住院后疼痛管理的指南。大型临床试验还没有在 急性SNF后，到目前为止，使用药物声明数据的观察性研究是不可能的，因为药物 SNF居民的Medicare Part D索赔不包括配药数据。有效和安全地治疗 老年人髋部骨折的疼痛，我们必须了解处方的驱动因素和下游影响 不同的止痛方案。这项提议有两个具体目标：(1)描述个人--(例如，ADRD) 和设施一级(例如，人员配备)使用不同止痛药方案的预测因素，包括那些 阿片类药物，用于髋部骨折后急性SNF护理；以及(2)评估比较疗效(即疼痛， 不同止痛方案的疗效)和安全性(即再次住院)。我们严格的队列研究 Proposal将结合新的关联管理和临床数据集来识别药物分配 60%的美国SNF的Medicare Part D中缺少的数据，包括非处方药和专业人员 NATA(PRN)使用。研究人群将包括居住在社区的老年人，他们因 在2013至2016年间髋部骨折，然后住进疗养院接受SNF治疗。主题将是 对SNF入院后的结果进行随访，比较不同止痛药的效果 急性后护理中的用药方案。这项研究的数据将来自(1)大型长期护理 药房，在无法获得D部分索赔数据的情况下，捕获SNF护理期间的药物使用情况； (2)最低数据集3.0版，标准化临床评估数据的综合数据库； (3)认证和检验普罗维登斯增强报告数据库，包含综合设施- 设施收集的级别信息；(4)联邦医疗保险A部分住院患者索赔数据；(5)联邦医疗保险D部分药物 索赔；以及(6)125个SNF的用药记录数据。倾向计分方法和其他 将采用因果推理方法。从这项研究中获得的知识可以提供第一个经验性的 指导老年人髋部骨折后疼痛的治疗，这最终可能导致改善 治疗决定和随后的患者健康结果，从而实现战略目标C 国家老龄问题研究所。此外，本项目中建立的唯一数据库可用于 进行许多重要的未来用药相关研究，以改善急性后护理中老年人的健康。

Project Summary Pain management in older adults is more important during the post-acute care period than at any other time after hip fracture hospitalization. Pain control can positively impact function and help avert adverse outcomes like delirium, especially among persons with Alzheimer’s disease and related dementias (ADRD). Annually, over 300,000 older U.S. adults are discharged to receive rehabilitation in post-acute skilled nursing facilities (SNFs) after hip fracture, making SNFs a critical place to study analgesic prescribing practices and their impact following fracture. Pain is often inadequately treated following hip fracture, and there are no evidence-based guidelines to guide post-hospitalization pain management. Large clinical trials have not been conducted in post-acute SNFs and until now, observational studies using drug claims data were impossible because drug dispensing data is not captured by Medicare Part D claims for SNF residents. To effectively and safely treat pain in older adults with hip fracture, we must understand the drivers and downstream effects of prescribing different analgesic regimens. This proposal has two specific aims: (1) To describe the individual- (e.g., ADRD) and facility-level (e.g., staffing) predictors of using different analgesic drug regimens, including those containing opioids, in post-acute SNF care after hip fracture; and (2) To evaluate the comparative effectiveness (i.e., pain, functioning) and safety (i.e., rehospitalization) of different analgesic regimens. The rigorous cohort study we propose will combine novel linked administrative and clinical datasets to identify the medication dispensing data that are “missing” from Medicare Part D for >60% of all U.S. SNFs, including over-the-counter and pro re nata (PRN) use. The study population will comprise community-dwelling older adults who were hospitalized for hip fracture between 2013 and 2016, and then admitted to a nursing home for a SNF stay. Subjects will be followed for outcomes after SNF admission, comparing those who were initiated on different analgesic medication regimens in post-acute care. Data for this study will come from (1) a large long-term care pharmacy, which captures drug use during periods of SNF care where claims data from Part D are unavailable; (2) the Minimum Data Set version 3.0, a comprehensive database of standardized clinical assessment data; (3) the Certification and Survey Providence Enhanced Reporting database containing comprehensive facility- level information collected on facilities; (4) Medicare Part A inpatient claims data; (5) Medicare Part D drug claims; and (6) medication administration record data for 125 SNFs. Propensity score approaches and other causal inference methods will be employed. Knowledge gained from this study could provide the first empirical guidance for the management of post-hip fracture pain in older adults, which could ultimately result in improved treatment decisions and subsequent patient health outcomes, thereby addressing Strategic Goal C of the National Institute on Aging. Additionally, the unique database established in this project could be used to conduct many important future medication-related studies to improve health of older adults in post-acute care.