Modifiable factors in emergent presentation of potentially elective general surgical disease for patients who are insured or insurance-eligible

对于有保险或符合保险资格的患者，紧急出现潜在选择性普通外科疾病时可修改的因素

• 批准号: 10394733
• 负责人: Catherine Garrison Velopulos
• 金额: $ 31.5万
• 依托单位: UNIVERSITY OF COLORADO DENVER
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-04-17 至 2026-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10394733
• 关键词: Acute; Admission activity; Affordable Care Act; American; Appointment; Area; Caring; Cholecystectomy; Chronic Disease; Classification; Clinical; Comb animal structure; Communication; Confusion; Consultations; Country; Data; Data Analyses; Data Collection; Data Set; Diagnosis; Disease; Disease Progression; Early Intervention; Eligibility Determination; Emergency Situation; Emergency department visit; Event; Fright; Future; Goals; Health; Health Services Accessibility; Healthcare; Healthcare Systems; Hospitalization; Income; Insurance; Insurance Coverage; International; Intervention; Interview; Language; Link; Manuals; Medicaid; Meta-Analysis; Methods; Modeling; Morbidity - disease rate; Operative Surgical Procedures; Outcome; Pain; Pathologic; Patients; Persons; Population; Primary Health Care; Privatization; Probability; Procedures; Race; Recording of previous events; Research; Research Methodology; Research Personnel; Risk; Schedule; Services; Social Work; Structure; Time; Transportation; Trauma; United States; Vulnerable Populations; World Health; acute care; billing data; biopsychosocial; cost; data modeling; demographics; design; disability; effective intervention; expectation; experience; innovation; interest; markov model; mortality; multiple data sources; novel; operation; prevent; prospective; social factors; social vulnerability; surgical disparities; systematic review

PROJECT SUMMARY/ABSTRACT The overall goal of our proposed research is to understand why having health care coverage (or eligibility for health care coverage) is not sufficient to allow equal access to elective surgical care. Despite successful efforts to expand coverage through Medicaid expansion and the Affordable Care Act (ACA), potentially elective surgical care is often not addressed until it becomes an emergency. These patients tend to come from vulnerable populations, who not only present more often for Emergency General Surgery (EGS), but experience worse outcomes and greater costs. The disparities leading to this presentation in the United States have been well-described in terms of overall relationship to insurance status, race and income, but deeper data collection and analysis are desperately needed to identify modifiable factors that can inform interventions around decreasing emergent presentation in these populations, particularly in regard to health care coverage. Even in countries with Universal Health Care systems, disparities are noted in how people are able to actually access those services. We initially studied this problem in the context of emergent cholecystectomy, one of our most common presentations of EGS disease. We found that lack of health care coverage was not a major factor; in fact, 86% of our patients had some type of coverage (29% private, 57% public), and many other social factors led to an emergency operation. We now seek to expand and explore this in detail for the other EGS conditions defined by the American Association for the Surgery of Trauma (AAST) using a multiphase mixed method approach. We will 1) identify modifiable factors for emergent presentation and explore the trajectory of progression to elective versus emergency surgery using billing data and EHR in a convergent mixed-methods design, combining quantitative variables with qualitative narrative data, 2) identify and quantify additional modifiable factors from the patient perspective that are not available in clinical or administrative datasets using an exploratory sequential design, using identified domains to conduct systematic review and meta-analysis for quantitative data, and 3) determine which modifiable factor or factors identified will have the greatest impact for future intervention strategies using Markov modeling. This proposal will leverage our ability to link data from multiple sources in novel ways, our diverse, robust general surgery population in a Medicaid expansion state, and Co-Investigators who are expert in their fields of longitudinal data modeling and mixed methods research. With this data we can model and understand what influences the persistent disparity in the ability to access elective surgical care despite increased coverage, and predict which factors contribute the most to the disparities and thus hold potential for the greatest impact. By identifying actionable modifiable factors, we will ultimately inform effective intervention strategies to prevent emergent presentation of elective surgical disease.

项目摘要/摘要 我们拟议的研究的总体目标是了解为什么拥有医疗保健覆盖范围（或资格 对于医疗保健覆盖范围）不足以允许平等获得选修手术护理。尽管成功 通过医疗补助扩展和《平价医疗法案》（ACA）的努力，可能是选修课 在紧急情况下，通常不会解决手术护理。这些患者往往来自 弱势群体，不仅为紧急普通手术（例如）出现更多的人，而且 体验更糟糕的结果和更高的成本。导致该演讲的差异 在与保险状况，种族和收入的整体关系方面已经描述了很好的描述，但是数据更深 迫切需要收集和分析来确定可修改的因素，以告知干预措施 在这些人群中减少新兴表现，特别是在医疗保健覆盖范围内。 即使在具有通用医疗保健系统的国家，人们也会注意到人们如何实际能够 访问这些服务。 我们最初在新兴的胆囊切除术中研究了这个问题，这是我们最常见的 EGS疾病的介绍。我们发现缺乏医疗保健范围不是主要因素。实际上，86％ 我们的患者中有某种类型的覆盖范围（私有29％，公开57％），许多其他社会因素导致了 紧急操作。现在，我们寻求扩大并详细探讨其他EGS条件定义的条件 由美国创伤手术协会（AAST）使用多相混合方法。 我们将1）确定可修改的因素，以探讨 使用计费数据和EHR在收敛的混合方法设计中，选修课与紧急手术， 将定量变量与定性叙事数据相结合，2）识别和量化其他修改 从患者的角度来看，临床或行政数据集中无法使用的因素 探索性顺序设计，使用已识别的域进行系统的审查和荟萃分析 定量数据和3）确定确定的可修改因素或因素将对 使用马尔可夫建模的未来干预策略。 该建议将利用我们以新颖的方式将数据链接到多种来源的能力 医疗补助扩张状态下的一般手术人群以及在其领域的专家 纵向数据建模和混合方法研究。使用这些数据，我们可以建模并了解什么 影响尽管覆盖范围增加，能够获得选修手术护理能力的持续差异， 并预测哪些因素对差异最大，从而对最大的影响有可能。 通过确定可行的可修改因素，我们最终将为有效的干预策略提供信息 出现选修外科疾病的出现。