The Effect of De-Prescribing Antipsychotics on Health and Quality of Life for People with Dementia

停用抗精神病药物对痴呆症患者健康和生活质量的影响

基本信息

批准号：
10328558
负责人：
Adam Jon Sacarny
金额：
$ 16.16万
依托单位：
COLUMBIA UNIVERSITY HEALTH SCIENCES
依托单位国家：
美国
项目类别：
财政年份：
2021
资助国家：
美国
起止时间：
2021-01-15 至 2023-12-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10328558
关键词：
Address Adult Adverse effects Affect Age Alzheimer&apos s disease related dementia Antipsychotic Agents Behavioral Behavioral Symptoms Caring Clinical Clinical Data Communities Conduct Clinical Trials Data Dementia Detection Discipline Discipline of Nursing Education Elderly Electronic Mail Evaluation Fee-for-Service Plans Future Goals Group Homes Guidelines Health Health Professional Healthcare Healthcare Systems Hospitalization Hyperlipidemia Impaired cognition Inpatients Intervention Lead Letters Location Long-Term Effects Longitudinal Studies Medicare Medicare claim Mental Depression Methods Nursing Homes Outcome Patient Care Patient-Focused Outcomes Patients Persons Pharmaceutical Preparations Physicians Policies Population Primary Care Physician Primary Health Care Quality of Care Quality of life Race Randomized Randomized Clinical Trials Randomized Controlled Trials Recording of previous events Research Research Personnel Safety Stroke Subgroup Techniques Testing United States Centers for Medicare and Medicaid Services Visit Vulnerable Populations Work base behavioral economics care outcomes cognitive function cohort cost dementia care design dual eligible follow-up health care disparity improved improved outcome intervention cost intervention effect mortality risk novel patient oriented patient population peer quetiapine side effect sociodemographic group sociodemographics stem tool

项目摘要

PROJECT SUMMARY Antipsychotics are frequently prescribed to older adults with Alzheimer’s disease and related dementias (ADRD) to treat behavioral symptoms, but clinical guidelines suggest their use should be limited in this population due to the possibility of adverse side effects. Recently, interventions have harnessed tools of behavioral economics such as “nudges” through letters and e-mails to raise prescribing quality. Organizations can deploy these interventions quickly, cheaply, and at scale. However, little evidence exists on using this work to address antipsychotic prescribing to patients with ADRD in spite of the enormous potential value it could have in this context. Moreover, even where evidence exists that interventions successfully cause “deprescribing”, given the possibilities for patient harms from indiscriminate cutbacks, these interventions merit careful evaluation. Our proposed study seeks to fill this evidence gap. We will analyze a novel trial conducted by the Centers for Medicare and Medicaid Services that randomized over 5,000 high-volume primary care physician prescribers of quetiapine, the most commonly used antipsychotic in the U.S., to overprescribing letters informed by behavioral economics. The letters included a peer comparison “nudge” and an overuse warning, and they reduced new initiations of quetiapine by 24% over two years. Our work focuses on the effects of these letters on clinical quality, quality of life, and health care use of dementia patients of these physicians. The physicians had over 40,000 patients with ADRD, a large cohort that will facilitate detection of both benefits and harms of deprescribing. We will exploit rich Medicare data, including nursing home assessments and health care claims, and will study effects for up to 5 years. We will proceed in three steps. In Aim 1, we will analyze effects of the intervention on ADRD patients of study prescribers who live in nursing homes, a particularly vulnerable population for whom extensive data on patient- centered outcomes is available. Through this data, we will closely track clinical and quality of life outcomes, including cognitive function, behavioral symptoms, and depression. In Aim 2, we will broaden our analyses to include dementia patients who live in the community, using claims data to track effects on health outcomes such as hyperlipidemia and stroke and health care use such as inpatient hospitalizations and primary care visits. Finally, in Aim 3 we will test whether effects of the letters differ for patients based on care setting, sociodemographic group, or nursing home quality; these results will show whether letters address or expand gaps in care quality and will determine which groups, if any, are appropriate for similar interventions in the future. Taken together, our results will show whether simple, behaviorally informed deprescribing efforts can encourage guideline-concordant care and improve outcomes for patients with dementia, or whether such interventions lead to unintended harms. Our findings will guide future policy on deploying low-cost and scalable interventions to improve the quality of care for older adults with ADRD.

项目概要抗精神病药物经常用于治疗患有阿尔茨海默病和相关痴呆症 (ADRD) 的老年人用于治疗行为症状，但临床指南建议应限制在该人群中使用它们，因为最近，干预措施利用了行为经济学的工具。例如通过信件和电子邮件“推动”以提高处方质量组织可以部署这些措施。快速、廉价、大规模的干预措施然而，很少有证据表明利用这项工作来解决这个问题。尽管抗精神病药在这方面可能具有巨大的潜在价值，但还是给 ADRD 患者开抗精神病药此外，即使有证据表明干预措施成功地导致了“处方减少”，但考虑到由于不加区别的削减可能对患者造成伤害，因此这些干预措施值得仔细评估。我们提出的研究旨在填补这一证据空白，我们将分析中心进行的一项新颖试验。医疗保险和医疗补助服务随机抽取了 5,000 多名初级保健医生开处方者喹硫平是美国最常用的抗精神病药物，根据行为学信息过度开出处方信这些信件包括同行比较“推动”和过度使用警告，并且他们减少了新的内容。两年内开始使用喹硫平的人数增加了 24%，我们的工作重点是这些信件对临床质量的影响。痴呆症患者的生活质量和医疗保健使用情况这些医生有超过 40,000 名。 ADRD 患者是一个庞大的队列，将有助于检测停用药物的益处和危害。将利用丰富的医疗保险数据，包括疗养院评估和医疗保健索赔，并将研究效果长达 5 年。我们将分三个步骤进行目标 1，我们将分析干预措施对研究 ADRD 患者的影响。居住在疗养院的处方者是一个特别脆弱的人群，对于他们来说，关于患者的大量数据通过这些数据，我们将密切跟踪临床和生活质量结果，包括认知功能、行为症状和抑郁。在目标 2 中，我们将分析范围扩大到以下方面。包括居住在社区的痴呆症患者，使用索赔数据来跟踪对健康结果的影响，例如如高脂血症和中风以及医疗保健用途，例如住院和初级保健就诊。最后，在目标 3 中，我们将测试字母对患者的影响是否因护理环境而异，社会人口群体或疗养院质量；这些结果将显示信件是否涉及或扩展护理质量方面的差距，并将决定哪些群体（如果有的话）适合未来采取类似的干预措施。总而言之，我们的结果将表明简单的、基于行为的处方努力是否可以鼓励符合指南的护理并改善痴呆症患者的治疗结果，或者此类干预措施是否会导致我们的研究结果将指导未来部署低成本且可扩展的干预措施的政策。提高患有 ADRD 的老年人的护理质量。