Using Outcomes to Guide Treatment of Surgical Emergencies

利用结果指导外科紧急情况的治疗

基本信息

批准号：
10152509
负责人：
Rachel Kelz
金额：
$ 50.29万
依托单位：
UNIVERSITY OF PENNSYLVANIA
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：
2019-05-15 至 2024-04-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10152509
关键词：
Accident and Emergency department Acute Address Admission activity Adult Age Algorithms Alzheimer&apos s disease related dementia Caregivers Caring Characteristics Clinical Clinical effectiveness Code Comparative Effectiveness Research Complication Coronary heart disease Critical Care Custom Data Data Set Dementia Development Diabetes Mellitus Diagnosis Durable Medical Equipment Effectiveness Elderly Emergency Care Emergency Situation Emergency treatment Enrollment Ensure Ethics Evaluation Future HIV Health Policy Health Priorities Health system Heart failure Heterogeneity Hospitalization Hospitals Individual Inferior Institute of Medicine (U.S.)Intervention Knowledge Link Literature Malignant Neoplasms Measures Medicare Methods Modeling Nature Observational Study Operative Surgical Procedures Outcome Patient Care Patient-Focused Outcomes Patients Pattern Performance Policy Maker Population Prevalence Procedures Process Provider Race Randomized Randomized Controlled Trials Recurrence Reporting Research Design Risk Severity of illness Stroke Structure Subgroup Surgeon System Technology Trauma Trauma patient Treatment Cost Treatment outcome United States Ursidae Family Variant Vulnerable Populations Work adverse outcome age effect base beneficiary care burden care seeking care systems comorbidity comparative effectiveness comparative effectiveness analysis comparative effectiveness study control trial cost design disorder risk emergency settings high risk hospital performance inpatient service insight instrument interest lifetime risk minimally invasive mortality novel older patient operation optimal treatments patient subsets preference provider factors readmission rates response service providers sociodemographic factors surgery outcome treatment effect treatment guidelines

项目摘要

Emergency general surgery (EGS) conditions are defined by a group of acute, non-trauma diagnoses that require presentation to an emergency department for operative or non-operative care. In the US, 3-4 million adults are hospitalized and treated for an EGS condition each year such that EGS conditions are responsible for 7% of all hospitalizations. EGS conditions result in an estimated 800,000 operations annually and cost ≈ $28 billion. The burden of EGS on inpatient care is greater than that of a new diagnosis of diabetes or cancer, coronary heart disease, heart failure, stroke, or HIV. Older adults, who are at increased risk of adverse outcomes, comprise more than half of the adult EGS population. Operative management of EGS conditions results in an overall complication rate of 50%, with a readmission rate of 4-18%, and a mortality rate that can approach 15%, with older patients demonstrating a significantly higher risk. Non-operative management is considered a reasonable alternative yet studies show mixed results. Randomized control trials are limited by the invasive nature of operative treatment, the heterogeneity of conditions, and the acute nature of EGS. Furthermore, most trials have compared different types of operative or non-operative interventions, with relatively few comparing operative treatment to non-operative treatment. A lack of evidence on the comparative effectiveness of operative and non- operative treatment has been shown to result in unnecessary variations in treatment and inferior operative outcomes. Furthermore, given the growing interest in the development of a regionalized system of care for EGS patients since the Institute of Medicine Committee report on the Future of Emergency Care in the United States Health System, knowledge on hospital performance in EGS is needed. This proposal aims to address these gaps in the literature with the following specific aims: (1) To identify hospital-level factors associated with rankings in EGS performance, (2) To evaluate the comparative effectiveness of operative and non-operative treatment in specific EGS conditions and (3) To evaluate heterogeneity in the effectiveness of operative treatment. Conditional effects of age, dementia and race will be examined amongst others. Using nationwide data from Medicare beneficiaries, the proposed study will be the first comparative effectiveness analysis of operative and non-operative treatment in EGS. The proposal employs: (1) template matching to define hospital quality in EGS (2) an instrumental variable approach with optimal near-far matching to overcome confounding by indication and, (3) interaction models to examine the conditional relationship between treatment and outcomes by patient factors. In so doing, the findings will provide insights into hospital factors necessary for optimal EGS outcomes and the comparative effectiveness of OP of EGS conditions. Policy makers will have evidence to inform systems- level restructuring to address the crisis in emergency care. Patients, caregivers and providers will benefit from the resultant high value care.

紧急通用手术（例如）疾病由一组急性的非创伤诊断来定义向急诊科进行操作或非手术护理。在美国，3-4万成年人是每年住院并治疗EGS状况住院。例如，估计每年进行80万行动，耗资约280亿美元。这 EGS对住院护理的负担大于糖尿病或癌症的新诊断冠心病的负担疾病，心力衰竭，中风或艾滋病毒。老年人患有不良后果的风险增加，完成超过一半的成年人人口。 EGS条件的手术管理会导致总体并发症率为50％，再入院率为4-18％，死亡率可能接近15％，而死亡率为15％老年患者表现出明显更高的风险。非手术管理被认为是合理的替代性研究表明结果不同。随机对照试验受到侵入性的限制手术治疗，条件的异质性以及EGS的急性性质。此外，大多数试验都有比较了不同类型的操作或非手术干预措施，相对较少比较操作治疗非手术治疗。缺乏有关操作和非相比有效性的证据已显示手术治疗会导致治疗和操作较低的不必要变化结果。此外，鉴于对EGS的区域化护理体系的开发越来越兴趣患者自医学研究所委员会报告美国的未来急诊室报告卫生系统，需要EGS医院表现的知识。该建议旨在解决这些问题文献中的差距具有以下特定目的：（1）确定与排名相关的医院级别因素在EGS性能中，（2）评估操作和非手术治疗的比较有效性特定的EGS条件和（3）评估手术治疗有效性的异质性。年龄，痴呆症和种族的有条件影响将在其他情况下进行检查。使用来自全国范围的数据 Medicare受益人，拟议的研究将是对操作和 EGS中的非手术治疗。提案员工：（1）模板匹配以定义EGS的医院质量（2）一种具有最佳接近匹配的仪器变量方法，以克服指示和，（3）检查患者治疗与结局之间有条件关系的相互作用模型因素。在这样做的情况下，这些发现将为最佳EGS结果所必需的医院因素提供见解 EGS条件的OP的比较有效性。政策制定者将有证据通知系统 - 重组以解决紧急护理危机。患者，照顾者和提供者将从最终的高价值护理。