Understanding Variation in Treatment Intensity with Lower Extremity PAD

了解下肢 PAD 治疗强度的变化

• 批准号: 8144324
• 负责人: Philip P Goodney
• 金额: $ 13.99万
• 依托单位: DARTMOUTH COLLEGE
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-09-15 至 2015-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8144324
• 关键词: Affect; African American; American; Amputation; Atlases; Award; Benefits and Risks; Blood Vessels; Bypass; Care given by nurses; Caring; Characteristics; Clinical; Clinical Data; Clinical Pathways; Clinical Sciences; Comorbidity; Consultations; Cost Analysis; Data; Data Set; Development Plans; Effectiveness; Elements; Ensure; Environment; Evaluation; Expenditure; Fellowship; Fostering; Funding; Gender; Goals; Health Care Delivery Study; Health Policy; Health Services Research; Healthcare; Hospitals; Image; Independent Living; Institutes; Intervention; Knee; Knowledge; Learning; Length of Stay; Link; Lower Extremity; Master' s Degree; Measurement; Measures; Medical; Medicare; Medicare claim; Mentors; Mentorship; Modeling; New England; Operative Surgical Procedures; Outcome; Outcomes Research; Patient Care; Patients; Peripheral arterial disease; Procedures; Provider; Quality of Care; Race; Reporting; Research; Research Project Grants; Risk; Role; Socioeconomic Status; Specialist; Statistical Methods; System; Testing; Time; Training; Translating; United States; Variant; Vascular Diseases; Work; base; career; career development; comparative effectiveness; cost; design; experience; health care delivery; improved; low socioeconomic status; patient population; population based; professor; public health relevance; regional difference; secondary outcome; shared decision making; treatment strategy

DESCRIPTION (provided by applicant): Early in my surgical training, I found the thought of having a career that affects not only clinical surgery, but also broader issues in the way health care is delivered, to be very appealing. Therefore, during surgical training, I received funding for a VA Special Fellowship in Outcomes Research to complete two years of training in health services research, and concurrently obtained a Master's Degree in Evaluative Clinical Sciences from The Dartmouth Institute (TDI). Now, as an assistant professor at Dartmouth in vascular surgery, I have some research experience, especially in the use of observational datasets to measure and predict surgical risk. However, I believe that this Award will help me to grow and achieve important short and long-term goals in building a lifelong research career. First, in terms of short term goals, this Award will expand my ability to measure the effects of variation in treatment in patients with lower extremity peripheral arterial disease (PAD). Second, my long term goal is to become a leader in vascular outcomes research, with a focus on designing clinical pathways and health policy aimed at helping patients make the best treatment choices. The ultimate goal of my research career will be to ensure that patients with vascular disease are well informed about the risks and benefits of different treatment strategies, so that they can make well-informed treatment choices. Three key elements of my career development plan will foster my efforts towards achieving these goals. First, through coursework in advanced observational statistical methods, I will ensure that I strengthen my ability to perform high-quality comparative effectiveness studies of competing treatments and strategies in lower extremity PAD. Second, through coursework in cost analysis, I will develop new expertise in cost measurement in health care. And third, I will use project-based learning to ensure that the didactic elements of my career development plan translate into action. For three reasons, TDI represents an ideal environment to pursue my research agenda. First, for over 20 years, TDI has been recognized as a national leader in studying health care delivery and effectiveness. TDI has produced national leaders in the evaluation of regional variation in the delivery and quality of care, outcomes analysis, and shared-decision-making. Second, I am fortunate to have the mentorship of one of TDI's leaders, Dr. Elliott Fisher. He has served as a mentor since my time as a VA Outcomes Fellow in 2002, continually through our recent efforts in measuring regional variation. And, third, TDI has developed a close relationship with the Vascular Study Group of New England, a regional quality improvement initiative centered at the Section of Vascular Surgery at Dartmouth. The VSGNE has served as a platform for piloting our work in linking clinical datasets to administrative data, as well as refining and testing our administrative prediction models with clinical data. My research project will examine the effect of variation in vascular treatment intensity on PAD-specific outcomes. Lower extremity peripheral arterial disease (PAD) affects over 12 million Americans, and results in nearly 100,000 major amputations (above or below-knee) annually in the United States. However, the risk of amputation from PAD varies ten-fold, depending on where patients reside. Research in the Dartmouth Atlas of Health Care has attributed some of these regional differences in amputation to patient-level factors, reporting five-fold higher amputation rates among blacks and those of low socioeconomic status (SES). However, such significant variation in amputation rates cannot be explained solely by patient factors; health care delivery to these patients varies significantly as well. Our preliminary work shows sizeable disparities in the intensity of vascular care received by patients in the year before they undergo major lower extremity amputation. These differences suggest that in some regions, far too little vascular care is being provided. In other regions, very intensive vascular care, with aggressive use of invasive revascularization procedures, may not necessarily translate into better outcomes for patients. Efforts to improve vascular care for patients with PAD will require better knowledge of the variation in intensity of care and its relationship to PAD-specific outcomes. In this proposal, I will characterize variation in the treatment of lower extremity PAD, explore the determinants of this variation, and study the relationship of intensity of vascular care to PAD-related outcomes. This project will inform my future research, aimed at better targeting the use of vascular care to achieve optimal outcomes in patients with lower extremity PAD. PUBLIC HEALTH RELEVANCE: The treatment intensity of patients with lower extremity peripheral arterial disease varies widely. A better understanding of the determinants of this variation, as well as the relationship between intensity of care and patient outcomes, will guide efforts to improve vascular care for all Americans with peripheral arterial disease.

描述（由申请人提供）：在我接受外科手术培训的早期，我发现自己的职业不仅影响临床手术，而且还影响医疗保健提供方式中更广泛的问题，这一想法非常有吸引力。因此，在外科培训期间，我获得了 VA 结果研究特别奖学金的资助，完成了两年的卫生服务研究培训，同时获得了达特茅斯研究所 (TDI) 的评估临床科学硕士学位。现在，作为达特茅斯血管外科的助理教授，我有一些研究经验，特别是在使用观察数据集来测量和预测手术风险方面。然而，我相信这个奖项将帮助我成长并实现建立终生研究事业的重要的短期和长期目标。首先，就短期目标而言，该奖项将扩大我衡量下肢外周动脉疾病（PAD）患者治疗变化效果的能力。其次，我的长期目标是成为血管结果研究的领导者，重点是设计临床路径和健康政策，旨在帮助患者做出最佳的治疗选择。我研究生涯的最终目标是确保血管疾病患者充分了解不同治疗策略的风险和益处，以便他们能够做出明智的治疗选择。 我的职业发展计划的三个关键要素将促进我努力实现这些目标。首先，通过高级观察统计方法的课程，我将确保增强对下肢 PAD 竞争治疗和策略进行高质量比较有效性研究的能力。其次，通过成本分析课程，我将发展医疗保健成本计量的新专业知识。第三，我将使用基于项目的学习来确保我的职业发展计划的教学要素转化为行动。 出于三个原因，TDI 为我的研究议程提供了一个理想的环境。首先，20 多年来，TDI 一直被认为是研究医疗保健服务和有效性方面的全国领先者。 TDI 培养了在评估护理服务的提供和质量的区域差异、结果分析和共同决策方面的国家领导者。其次，我很幸运能够得到 TDI 领导人之一 Elliott Fisher 博士的指导。自 2002 年我担任 VA 结果研究员以来，他一直担任我的导师，并不断帮助我们最近衡量地区差异的努力。第三，TDI 与新英格兰血管研究组建立了密切的关系，这是一项以达特茅斯血管外科部门为中心的区域质量改进计划。 VSGNE 充当了一个平台，用于试点我们将临床数据集与管理数据联系起来的工作，以及利用临床数据完善和测试我们的管理预测模型。 我的研究项目将研究血管治疗强度的变化对 PAD 特异性结果的影响。下肢外周动脉疾病 (PAD) 影响着超过 1200 万美国人，每年在美国导致近 100,000 例大截肢（膝盖以上或以下）。然而，根据患者居住地的不同，外周动脉疾病 (PAD) 截肢的风险会相差十倍。达特茅斯医疗保健地图集的研究将截肢的部分地区差异归因于患者层面的因素，报告称黑人和社会经济地位较低的人的截肢率高出五倍。 然而，截肢率的如此显着差异不能仅用患者因素来解释；为这些患者提供的医疗保健服务也存在很大差异。我们的初步工作表明，患者在接受重大下肢截肢前一年接受的血管护理强度存在相当大的差异。这些差异表明，在某些地区，提供的血管护理太少。在其他地区，非常密集的血管护理，以及积极使用侵入性血运重建手术，可能不一定会为患者带来更好的结果。 为了改善 PAD 患者的血管护理，需要更好地了解护理强度的变化及其与 PAD 特异性结果的关系。在本提案中，我将描述下肢 PAD 治疗的差异，探讨这种差异的决定因素，并研究血管护理强度与 PAD 相关结果的关系。该项目将为我未来的研究提供信息，旨在更好地针对血管护理的使用，以实现下肢 PAD 患者的最佳结果。 公共卫生相关性：下肢外周动脉疾病患者的治疗强度差异很大。更好地了解这种差异的决定因素以及护理强度与患者结果之间的关系，将指导改善所有患有外周动脉疾病的美国人的血管护理的努力。