Multimorbidity and Screening Colonoscopy: A Framework for Patients and Policy

多发病和筛查结肠镜检查：患者和政策框架

• 批准号: 7678587
• 负责人: Cary P. Gross
• 金额: $ 13.87万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2008
• 资助国家: 美国
• 起止时间: 2008-09-01 至 2011-02-28
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7678587
• 关键词: Multimorbidity; Screening; Colonoscopy; Framework; Patients

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.

描述（由申请人提供）：许多老年人患有多种同时发生的慢性病或“多种疾病”。在审查护理质量的时候，多医生对基于证据的筛查指南的解释和应用提出了一个独特的挑战。例如，筛查结肠镜检查被广泛认为是有效和没有用的，而有资格的患者进行了该手术。然而，筛查结肠镜检查的潜在益处可能会根据年龄和多种多发性负担而有很大差异。尽管直观的是老年患者从筛查结肠镜检查中获得的收益较少，但仍需要基于人口数据的框架来确定多种多发性多种多发性的老年人可能会受到筛查结肠镜检查的收益。该框架将促进床旁的个性化决策，告知筛查指南的修订，并允许关注最有可能从筛查结肠镜检查中受益的患者的护理质量计划。同样重要的是考虑将预防策略定位到慢性病负担较低的人们中如何可能会对脆弱的人群产生不利影响，他们的成员带来了更大的慢性病负担。拟议工作的目的是进一步理解多种多发病，性别和年龄如何影响筛查结肠镜检查的风险和好处，以开发可应用于其他预防性健康干预措施的框架。有关结直肠癌癌症患者的基于人群的信息，将从链接的监测，流行病学和最终结果（SEER） - 梅迪卡雷数据库中获得。我们将估计（AIM 1），作为年龄，性别和多种疾病的函数，筛查结肠镜检查对预期寿命的影响，以及最早的筛查结肠镜检查收益超过增量危害（即收益时间）的最早时间。在使用建模方法来制定简单，可运输的决策规则，以确定哪些患者可能或不太可能从1次筛查结肠镜检查中受益（AIM 2），Medicare索赔数据将用于确定人口级别的收益，如果结直肠癌筛查将与这些决策规则更加吻合，该益处将获得累积的益处（AIM 3）。最后，我们将根据我们对弱势群体（包括少数族裔种族和社会经济地位较低的人）进行的决策规则，根据筛查结肠镜检查和过度死亡率来研究筛查结肠镜检查的效果（AIM 4）。由此产生的数据将通过提供明确的决策规则以及描述对所有人口，弱势群体人群和个别患者实施此类规则的含义，从而为床边和卫生系统级别的决策提供信息。