Optimizing Medical Decision Making for Older Patients with Type 2 Diabetes

优化老年 2 型糖尿病患者的医疗决策

基本信息

批准号：
10395436
负责人：
ELBERT S. HUANG
金额：
$ 62.64万
依托单位：
KAISER FOUNDATION RESEARCH INSTITUTE
依托单位国家：
美国
项目类别：
财政年份：
2019
资助国家：
美国
起止时间：
2019-09-15 至 2024-04-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10395436
关键词：
Address Adherence Adult Adverse drug event Advocate Age American Behavior California Caring Clinical Clinical Data Clinical Trials Complex Complications of Diabetes Mellitus Conflict (Psychology)Data Data Reporting Decision Making Diabetes Mellitus Diagnosis Disease Drug Prescriptions Elderly Ensure Ethnic group Funding Future Geriatrics Glucose Goals Guidelines Health Health Policy Health Status Heterogeneity Hypoglycemia Knowledge Life Expectancy Link Longitudinal cohort Medical Modeling Non-Insulin-Dependent Diabetes Mellitus Observational Study Outcome Patient Outcomes Assessments Patient Preferences Patient Self-Report Patients Pharmaceutical Preparations Population Population Heterogeneity Provider Public Health Quality of life Recommendation Regimen Registries Research Research Proposals Risk Safety Sampling Self Management Societies Surveys Time Uncertainty United States National Institutes of Health Variant adverse outcome base clinical decision-making clinical practice cohort comorbidity disability ethnic diversity evidence base experience falls functional disability glycemic control human old age (65+)macrovascular disease mortality multi-ethnic older patient overtreatment patient registry personalized care predictive modeling preference racial diversity response risk stratification shared decision making support tools tool treatment strategy

项目摘要

Project Abstract Management of type 2 diabetes (T2D) in older patients is currently hampered by the lack of evidence needed to inform effective medical decision making. Older patients with diabetes are highly heterogeneous with regards to life expectancy, duration of diabetes, comorbidities, diabetic complications, disabilities, functional impairments, and treatment preferences. Current clinical guidelines all acknowledge this heterogeneity and support the concept of individualized diabetes care, but provide conflicting recommendations regarding how to individualize glycemic targets and medication regimens. These conflicts reflect the lack of evidence regarding the dynamic interactions between treatments, health status, and medical decision making in real-world clinical practice populations. While the patient perspective is a pillar of shared decision making, little is known about the variation in older patients' treatment preferences and experiences with current diabetes treatments, including self-management barriers and self-reported adverse drug events. Similarly, basic evidence is lacking on how the relationship between A1C and key outcomes varies by medical complexity and by classes of glucose-lowering medications. Moreover, busy clinicians lack practical, evidence-based tools to guide decision making regarding individualized targets and medications. Our overarching goal is to conduct observational research to provide evidence needed to inform safe and effective care of older adults with T2D. This research will be based on a well-characterized, multi-ethnic population of 145,894 patients ≥65 years old with T2D from Kaiser Permanente Northern California. We will use the results of a NIA-funded survey (R56 AG051683) in an age-stratified, random sample of ~6,000 patients to characterize patient perspectives on treatment preferences, self-management barriers, and patient-related outcomes (e.g., hypoglycemia, falls, quality of life). In this proposed study, we will link survey responses to EMR-based exposures and outcomes (e.g., labs, medication prescribing and adherence, complications, mortality). This will allow us to characterize variation in older patient's experiences with and preferences for diabetes treatments and examine the relationships between patient preferences and self-management barriers with past or future glycemic control, medication use and outcomes (Aim 1). To inform efforts to establish appropriate glycemic targets, we will identify A1C levels that are associated with the lowest risk of key adverse diabetes outcomes (micro- and macrovascular complications, mortality, and hypoglycemia), stratified by health status, age, diabetes duration, and medication type (Aim 2). Finally, we will create a decision support tool to encourage the individualization of diabetes care, maximizing safety and minimizing overtreatment, in older adults with T2D (Aim 3). This effort includes developing and validating a contemporary mortality prediction model and integrating it with our existing hypoglycemia risk stratification model. The completion of the proposed studies will ensure that older patients and their providers have the clinical evidence and support necessary to make informed decisions for diabetes.

项目摘要目前，由于缺乏所需证据，老年患者 2 型糖尿病 (T2D) 的治疗受到阻碍为做出有效的医疗决策提供信息老年糖尿病患者具有高度异质性。关于预期寿命、糖尿病持续时间、合并症、糖尿病并发症、残疾、功能当前的临床指南都承认这种异质性并且支持个体化糖尿病护理的概念，但就如何护理提供相互矛盾的建议个体化血糖目标和药物治疗方案反映了缺乏相关证据。现实临床中治疗、健康状况和医疗决策之间的动态相互作用虽然患者的观点是共同决策的支柱，但人们对此知之甚少。老年患者的治疗偏好和当前糖尿病治疗经验的变化，包括自我管理障碍和自我报告的药物不良事件同样缺乏基本证据。关于 A1C 与关键结果之间的关系如何因医疗复杂性和类别而异此外，忙碌的人群缺乏实用的、基于证据的工具来指导决策。我们的总体目标是进行观察。这项研究旨在提供安全有效护理老年 T2D 所需的证据。将基于 145,894 名年龄≥65 岁的 T2D 患者组成的特征明确的多种族人群北加州 Kaiser Permanente 我们将在一项由 NIA 资助的调查 (R56 AG051683) 中使用结果。对约 6,000 名患者进行年龄分层的随机抽样，以描述患者对治疗的看法偏好、自我管理障碍和患者相关结果（例如低血糖、跌倒、生活质量）。在这项拟议的研究中，我们将把调查回复与基于 EMR 的暴露和结果联系起来（例如，实验室、药物处方和依从性、并发症、死亡率）这将使我们能够描述差异的特征。老年患者对糖尿病治疗的经历和偏好并检查其中的关系患者偏好与过去或未来血糖控制、药物治疗的自我管理障碍之间的关系用途和结果（目标 1）为了为建立适当的血糖目标提供信息，我们将确定 A1C。与关键不良糖尿病结局（微血管和大血管）的最低风险相关的水平并发症、死亡率和低血糖），按健康状况、年龄、糖尿病病程和药物进行分层最后，我们将创建一个决策支持工具来鼓励糖尿病护理的个体化，最大限度地提高患有 T2D 的老年人的安全性并最大限度地减少过度治疗（目标 3）。开发和验证当代死亡率预测模型并将其与我们现有的集成所提出的研究的完成将确保老年患者的低血糖风险分层模型。及其提供者拥有做出糖尿病决策所需的临床证据和支持。