Using Outcomes to Guide Treatment of Surgical Emergencies

利用结果指导外科紧急情况的治疗

• 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
• 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' 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

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.

紧急普通外科(EGS)情况由一组急性、非创伤性诊断定义，这些诊断需要 送到急诊科接受手术或非手术治疗。在美国，300-400万成年人 每年因EGS疾病住院和治疗，EGS疾病占所有EGS疾病的7% 住院治疗。EGS的状况每年导致约800,000次手术，并花费≈280亿美元。这个 EGS对住院护理的负担比新诊断的糖尿病或癌症、冠心病更大 疾病、心力衰竭、中风或艾滋病毒。老年人有更高的不良后果风险，包括 超过一半的成年EGS人口。EGS条件的运行管理导致总体 并发症发生率为50%，再住院率为4-18%，死亡率可接近15%， 年龄较大的患者表现出明显更高的风险。非手术治疗被认为是合理的 然而，另一项研究显示，结果喜忧参半。随机对照试验受到侵袭性的限制 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 比较不同类型的手术或非手术干预，比较手术干预的相对较少 治疗以非手术治疗为主。缺乏关于手术和非手术的相对有效性的证据 手术治疗已被证明会导致治疗上不必要的变化和较差的手术 结果。此外，鉴于人们对发展区域性EGS护理系统的兴趣与日俱增 自医学研究所委员会关于美国急救未来的报告以来的患者 卫生系统，需要关于急救系统中的医院绩效的知识。这项提案旨在解决这些问题 文献中的差距，具体目标如下：(1)确定与排名相关的医院级因素 在脑电地形图表现方面，(2)评价手术和非手术治疗的疗效。 (3)评价手术治疗效果的异质性。 除其他因素外，还将考察年龄、痴呆症和种族等因素的条件影响。使用来自全国的数据 医疗保险受益人，拟议的研究将是第一次比较有效性分析手术和 EGS的非手术治疗。该方案采用：(1)模板匹配来定义EGS中的医院质量 (2)具有最佳远近匹配以克服指示混杂的工具变量方法， (3)检验患者治疗和结果之间条件关系的交互模型 各种因素。通过这样做，这些发现将提供对医院因素的洞察，这些因素是实现最佳EGS结果所必需的 以及EGS条件下OP的比较有效性。政策制定者将有证据告知系统- 层级重组，以解决紧急护理方面的危机。患者、照顾者和提供者将受益于 由此产生的高价值护理。