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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.

急诊普通外科（EGS）条件是由一组急性，非创伤诊断，需要在急诊科进行手术或非手术护理。在美国，300万至400万成年人每年因EGS状况住院和治疗，使得EGS状况占所有患者的7%。住院治疗环境商品和服务条件每年造成估计80万次手术，耗资280亿美元。的 EGS对住院治疗的负担大于新诊断的糖尿病或癌症、冠心病心脏衰竭中风或艾滋病老年人，谁是在不良后果的风险增加，包括超过一半的成年EGS人口。EGS条件的手术管理导致总体并发症发生率为50%，再入院率为4- 18%，死亡率可接近15%，老年患者的风险明显更高。非手术治疗被认为是合理的然而，其他研究显示出好坏参半的结果。随机对照试验受到创伤性的限制，手术治疗、病情的异质性和EGS的急性性质。此外，大多数审判比较了不同类型的手术或非手术干预，比较手术干预的相对较少。非手术治疗。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中不必要的变化，结果。此外，鉴于人们对发展区域化的环境和营养服务系统的兴趣日益浓厚，自医学研究所委员会关于美国急诊护理未来的报告以来，卫生系统，需要了解EGS中的医院绩效。该提案旨在解决这些问题在文献中的差距与以下具体目标：（1）确定医院水平的因素与排名（2）比较手术与非手术治疗对EGS的疗效，（3）评价手术治疗效果的异质性。年龄、痴呆和种族的条件效应将被检查。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个比较有效的分析， EGS的非手术治疗。该方案采用：（1）模板匹配法定义EGS中的医院质量 (2)具有最佳远近匹配的工具变量方法，以克服指示的混淆， (3)相互作用模型，以检查治疗与患者结局之间的条件关系因素在这样做的过程中，研究结果将提供对最佳EGS结果所需的医院因素的见解以及EGS条件下OP的相对有效性。政策制定者将有证据告知系统- 一级重组，以解决危机的紧急护理。患者、护理人员和提供者将受益于由此产生的高价值护理。