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

• 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
• 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

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 目前缺乏所需的证据，目前对老年患者的2型糖尿病（T2D）的治疗受到阻碍 告知有效的医疗决策。糖尿病的老年患者高度异质 考虑预期寿命，糖尿病持续时间，合并症，糖尿病并发症，残疾，功能 障碍和治疗偏好。当前的临床准则都承认这种异质性和 支持个性化糖尿病护理的概念，但就如何 个性化血糖靶标和药物方案。这些冲突反映了缺乏有关的证据 现实世界中的治疗，健康状况和医疗决策之间的动态互动 练习人口。虽然患者的观点是共同决策的支柱，但对 老年患者治疗偏好和当前糖尿病治疗的经历的变化， 包括自我管理障碍和自我报告的不良药物事件。同样，缺乏基本证据 关于A1C和关键结果之间的关系如何因医学复杂性以及类别的类别而异 降糖药物。此外，繁忙的临床医生缺乏指导决策的实用，基于证据的工具 关于个性化的靶标和药物。我们的总体目标是进行观察 提供的研究提供了所需的证据，以告知T2D老年人的安全有效护理。这项研究 将基于145,894例≥65岁患者的特征良好的多种族人口，T2D来自 Kaiser Permanente北加州。我们将在A中使用NIA资助的调查（R56 AG051683）的结果 年龄分层的，随机样本的约6,000名患者，以表征患者的治疗观点 偏好，自我管理障碍和与患者有关的结果（例如低血糖，跌倒，生活质量）。 在这项拟议的研究中，我们将将调查响应与基于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）。这将使我们能够表征 老年患者在糖尿病治疗方面的经历和偏好并检查关系 在患者的偏好和过去或将来血糖控制的自我管理障碍之间，药物 使用和结果（AIM 1）。为了努力建立适当的血糖靶标，我们将确定A1C 与关键广告糖尿病结果的最低风险相关的水平（微血管和大血管 并发症，死亡率和低血糖），按健康状况，年龄，糖尿病持续时间和药物分层 类型（AIM 2）。最后，我们将创建一个决策支持工具，以鼓励糖尿病护理的个性化， 在T2D的老年人中，最大化安全性并最大程度地减少过度治疗（AIM 3）。这项工作包括 开发和验证当代死亡率预测模型，并将其与我们现有的 低血糖风险分层模型。拟议研究的完成将确保老年患者 他们的提供者提供了为糖尿病做出明智决定所必需的临床证据和支持。