Evaluating Control of Hypertension - Effect of Social Determinants (ECHOES)

项目摘要 高血压(HTN)是美国成年人最常见的慢性疾病。未投保 成年人更有可能患有未确诊的HTN，不太可能接受定期筛查，也不太可能 与投保的成年人相比，他们的HTN得到了控制。先前对各州扩大医疗补助的研究 显示获得保险增加了医疗服务的利用率，收到了建议的预防措施 护理和改善健康结果；但由于没有对照组，这些研究受到限制。更多 最近，多个州受到联邦政策变化的影响(例如，《平价医疗法案》[ACA])，创造了 评估获得(或失去)医疗保险是否以及如何改善HTN预防的自然实验 和关心。此外，各州在选择扩大或缩小覆盖范围的方式上存在差异，这创造了 确定“干预”和“控制”州的机会(例如，一些州扩大了医疗补助资格，而 其他人则没有)。我们已经准备好研究ACA医疗补助扩大自然政策实验和其他 未来几年可能出现的政策变化。此外，通过医疗保险获得护理的机会可以 不足以减少HTN护理的障碍。因此，健康的其他社会决定因素([SDOH]；例如， 个人和社区层面的因素)可能不同地影响获得保险之间的关系 并接受HTN护理。我们将使用来自高级临床数据的电子健康记录(EHR)数据 研究网络，链接到社区层面的SDOH，它拥有来自599个社区卫生中心的数据 (CHC)，包括14个医疗补助扩展州的376个CHC(n=1,139,779名患者)和8个非 扩张状态(658,306例)。从该数据集中，我们将收集有关以下内容更改的详细信息 HTN的发病率、筛查、治疗和管理比较扩大医疗补助的州和那些 但事实并非如此。具体目标如下：目的1.比较HTN发病率、未确诊患病率 HTN和HTN筛查率，在医疗补助扩展与非扩展状态下， ACA.目的2.比较医疗补助扩展和非扩展状态下HTN的治疗和管理， 在ACA前后。目的3.评估HTN的发病率、筛查和治疗率 获得保险的患者与继续投保或未投保的患者在投保前的有效性 ACA，是由个人层面的SDOH(如种族、族裔)调节的。目标4.探索两者之间的互动 社区一级的SDOH(例如，邻里种族隔离和剥夺)和HTN筛查、治疗、 以及对获得保险的患者的管理，相对于那些已经投保或 没有保险，处于扩张状态。我们将直接建立在前期工作的基础上，并利用多样化的 我们多学科团队的优势。高级数据集使我们能够评估当前和 未来的自然实验。调查结果将与旨在缓解以下问题的政策和做法变化相关 HTN对弱势人群的护理存在差异。

Project Summary Hypertension (HTN) is the most common chronic condition among adults in the United States (US). Uninsured adults are more likely to have undiagnosed HTN, less likely to receive regular screening, and less likely to have their HTN under control than insured adults. Prior studies of individual states' Medicaid expansion showed that gaining insurance increased healthcare service utilization, receipt of recommended preventive care, and improved health outcomes; but these studies were limited by having no comparison group. More recently, multiple states were impacted by federal policy changes (e.g., Affordable Care Act [ACA]), creating `natural experiments' to assess whether and how gaining (or losing) health insurance improves HTN prevention and care. Further, there is variability in how states choose to expand or contract coverage, which creates opportunities to identify `intervention' and `control' states (e.g., some states expanded Medicaid eligibility, while others did not). We are well-poised to study the ACA Medicaid expansion natural policy experiment and other policy changes that may unfold in the next few years. In addition, access to care through health insurance may be insufficient to reduce barriers to HTN care. Thus, other social determinants of health ([SDOH]; e.g., individual- and community-level factors) may differentially affect the relationship between gaining insurance and receiving HTN care. We will use electronic health record (EHR) data from the ADVANCE clinical data research network, linked to community-level SDOH, which has data from 599 community health centers (CHCs), including 376 CHCs in 14 Medicaid expansion states (n=1,139,779 patients) and 224 CHCs in 8 non- expansion states (n=658,306 patients). From this dataset, we will collect detailed information on changes in HTN incidence, screening, treatment, and management comparing states that expanded Medicaid, and those that did not. The specific aims are as follows: Aim 1. Compare HTN incidence, prevalence of undiagnosed HTN, and rates of HTN screening, in Medicaid expansion versus non-expansion states before and after the ACA. Aim 2. Compare HTN treatment and management in Medicaid expansion versus non-expansion states, before and after the ACA. Aim 3. Assess the extent to which rates of HTN incidence, screening, and treatment effectiveness among patients who gained insurance versus those continuously insured or uninsured, pre-post ACA, are moderated by individual-level SDOH (e.g., race, ethnicity). Aim 4. Explore the interaction between community-level SDOH (e.g., neighborhood racial segregation and deprivation) and HTN screening, treatment, and management among patients who gained insurance relative to those who were already insured or uninsured, in expansion states. We will build directly on our preliminary work and take advantage of the diverse strengths of our multidisciplinary team. The ADVANCE dataset uniquely positions us to assess current and future natural experiments. Findings will be relevant to policy and practice changes aimed at mitigating disparities in HTN care for vulnerable populations.