Determining disparities in care quality for patients with acute respiratory failure and sepsis: the role of hospital-wide capacity strain

摘要 种族和少数民族患者分担过重的疾病负担和更糟糕的结局 生病了。尤其是黑人患者不仅罹患急性呼吸道疾病的风险更高 衰竭(ARF)和败血症，但也增加了死亡的风险。患有ARF或脓毒症的患者通常会接受 重症监护病房(ICU)或普通内科病房的医疗护理。通常情况下，大多数人会认为 分诊地点的决定只会基于疾病的严重程度。然而，医院层面的因素可能 影响分类决策。能力紧张，定义为护理单元提供高质量服务的能力受到限制 由于资源的原因，对患者的护理一直与医疗决策有关。产能紧张是一种 重要的系统现象，因为它(1)是所有急性医疗系统的共同现象，(2)容易察觉 由医疗保健提供者提供，以及(3)与不良的临床结果有关。尽管越来越多的文献表明 能力紧张在医疗保健运营中的作用，以前没有任何研究被设计来确定 种族和少数民族患者的能力紧张、差异和临床结果之间的关系。 确定危重病患者的能力紧张和医疗保健差距的作用对于(1)充分 描述能力紧张、危重疾病和患者预后之间的关系，(2)发展 理解医院内操作如何可能有助于发展应有的差异的框架 结构限制，以及(3)确定系统一级的目标，以实施旨在减少 医疗保健方面的差距。这样的分析可能对重新构建对 通过强调院内危险因素对其发展的重要性，提高对危重疾病的认识。这将会 与目前主要关注定义高绩效的医院间因素的解释形成对比 和表现不佳的危重疾病护理中心。 这项研究的目标是(1)了解医院范围内的能力紧张、ICU分诊、 ARF和脓毒症患者群体中的种族/民族差异，以及(2)评估差异 在ARF和脓毒症患者中，种族/民族之间因ICU分诊而受益的情况。首先，我的目标是使用 识别重要的社会人口学变量并评估其效果的多变量建模技术 不同容量应激指标与患者种族/民族之间的修正。接下来，我的目标是使用因果效应 方法评估不同种族/民族患者对ICU的益处。 该项目将为计划中的NIH K系列职业发展奖提供必要的初步数据 将(1)评估能力紧张对整个患者在紧急情况下的临床护理的累积影响 科室、ICU和病房，(2)评估不同分诊模式造成的经济差异，以及(3) 制定实施干预措施，以减少以患者为中心的相关结果的差异 全医院范围内的产能紧张。

Abstract Patients who are racial and ethnic minorities share excessive burden of disease and worse outcomes for critical illness. Black patients in particular are not only at higher risk of developing diseases such as acute respiratory failure (ARF) and sepsis, but also at increased risk of mortality. Patients with ARF or sepsis generally receive medical care in either the intensive care unit (ICU) or the general medicine ward. Typically, most would believe that the decision for triage location would only be based on illness severity. However, hospital level factors may influence triage decisions. Capacity strain, defined as a limitation in a care unit's ability to deliver high-quality care to patients due to resources, has been associated with healthcare decision making. Capacity strain is an important systems phenomenon because it is (1) common to all acute healthcare systems, (2) readily perceivable by healthcare providers, and (3) associated with poor clinical outcomes. Despite growing literature demonstrating the role of capacity strain in healthcare operations, no previous study has been designed to identify the relationship between capacity strain, disparities, and clinical outcomes for racial and ethnic minority patients. Determining the role of capacity strain and healthcare disparities for critically ill patients is crucial to (1) fully characterize the relationship between capacity strain, critical illness, and patient outcomes, (2) develop a framework for understanding how intrahospital operations may contribute to the development of disparities due to structural limitations, and (3) identify system-level targets for implementation initiatives designed to reduce healthcare disparities. Such analyses could be pivotal in reframing common understanding of disparities in critical illness by emphasizing the importance of intrahospital risk factors for their development. This would contrast to current interpretations that focus primarily on between-hospital factors that define high-performing and low-performing critical illness care centers. The goals of this study are to (1) understand the relationship between hospital-wide capacity strain, ICU triage, and racial/ethnic disparities in a population of patients with ARF and sepsis, and (2) assess for disparities between races/ethnicities in benefits due to ICU triage among patients with ARF and sepsis. First, I aim to use multivariable modeling techniques to identify important sociodemographic variables and assess for effect modification between various capacity strain metrics and patient race/ethnicity. Next, I aim to use causal effect methods to assess for ICU benefits among different patient race/ethnicities. This project will provide essential preliminary data for a planned NIH K-series Career Development Award that will (1) assess for the cumulative impact of capacity strain throughout a patients clinical care in the emergency department, ICU, and ward, (2) assess for economic disparities resulting from differential triage patterns, and (3) develop implementation interventions to mitigate disparities in patient-centered outcomes associated with hospital-wide capacity strain.