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: 10617230
• 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/10617230
• 关键词: Acute; Admission activity; Affordable Care Act; American; Appointment; Area; Caring; Categories; Cholecystectomy; Chronic Disease; Classification; Clinical; Communication; Confusion; Consultations; Country; Data; Data Analyses; Data Collection; Data Set; Diagnosis; Disease; Disease Progression; Disparity; 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; Phase; Population; Primary 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 Organization; 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; surgical service; 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.

项目概要/摘要 我们提出的研究的总体目标是了解为什么拥有医疗保健保险（或资格） 医疗保险）不足以让人们平等地获得择期手术护理。尽管成功 通过扩大医疗补助计划和《平价医疗法案》(ACA) 来扩大覆盖范围的努力，可能是可选的 手术护理往往直到紧急情况才得到解决。这些患者往往来自 弱势群体，他们不仅更频繁地接受普通外科急诊 (EGS)，而且 经历更糟糕的结果和更大的成本。导致美国这次演讲的差异 与保险状况、种族和收入的总体关系已得到很好的描述，但更深入的数据 迫切需要收集和分析来确定可以为干预措施提供信息的可修改因素 围绕减少这些人群的紧急情况，特别是在医疗保健覆盖方面。 即使在拥有全民医疗保健系统的国家，人们在实际获得医疗服务的能力方面也存在差异。 访问这些服务。 我们最初在紧急胆囊切除术的背景下研究了这个问题，这是我们最常见的手术之一 EGS 疾病的介绍。我们发现缺乏医疗保健覆盖并不是一个主要因素；事实上，86% 我们的患者有某种类型的保险（29% 是私人保险，57% 是公共保险），许多其他社会因素导致了 紧急操作。我们现在寻求针对定义的其他 EGS 条件来详细扩展和探索这一点 由美国创伤外科协会 (AAST) 采用多阶段混合方法进行。 我们将 1）确定紧急呈现的可修改因素并探索进展轨迹 在聚合混合方法设计中使用计费数据和 EHR 进行选择性手术与紧急手术， 将定量变量与定性叙述数据相结合，2）识别并量化其他可修改的变量 从患者角度来看的因素在临床或管理数据集中无法使用 探索性序贯设计，使用已确定的领域进行系统回顾和荟萃分析 定量数据，以及 3) 确定哪些可修改的因素或已识别的因素将产生最大的影响 使用马尔可夫模型的未来干预策略。 该提案将利用我们以新颖的方式链接多个来源的数据的能力，我们多样化、强大的 医疗补助扩张州的普外科人群，以及各自领域的专家联合研究者 纵向数据建模和混合方法研究。有了这些数据，我们可以建模并理解什么 尽管覆盖率有所增加，但影响了获得择期手术护理的能力的持续差异， 并预测哪些因素对差异影响最大，从而具有产生最大影响的潜力。 通过识别可采取行动的可改变因素，我们最终将提供有效的干预策略来预防 选择性外科疾病的紧急表现。