Multimorbidity and Screening Colonoscopy: A Framework for Patients and Policy

描述(由申请人提供)：许多老年人患有多种慢性疾病，或“多发病”。在对护理质量的审查日益严格的时候，多发性疾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和未得到充分利用的，接受该程序的合格患者太少。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的不同而有很大不同。虽然直观的是，年龄较大、病情较重的患者从筛查结肠镜检查中获益较少，但需要一个基于人口数据的框架，以确定患有不同多病负担的老年人有望从筛查结肠镜检查中受益多少。这一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，并允许将护理质量倡议的重点放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，考虑到针对慢性病负担较轻的人的预防战略如何可能对易受伤害的人群产生不利影响，因为这些人群的成员承担着较大的慢性病负担。这项拟议工作的目的是加深我们对多发病、性别和年龄如何影响筛查结肠镜检查的风险和好处的理解，目的是开发一个可应用于其他预防性卫生干预的框架。有关患有结直肠癌的老年癌症患者的基于人群的信息将从联系监测、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益处超过增量危害的最早时间(即，回报时间)。在使用建模方法开发了简单、可移植的决策规则以确定哪些患者可能或不可能从一次性筛查结肠镜检查中受益(目标2)后，联邦医疗保险声称数据将用于确定如果结直肠癌筛查更紧密地与这些决策规则一致将产生的人群水平的好处(目标3)。最后，我们将根据我们计算的决策规则，在筛查结肠镜检查和总体死亡率方面，检查重新分配筛查结肠镜检查对弱势人群的影响，包括少数族裔和社会经济地位较低的人群(目标4)。由此产生的数据将通过提供明确的决策规则以及描述实施这些规则对全体人口、弱势群体成员和个别患者的影响，为床边和卫生系统层面的决策提供信息。

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.