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

摘要 少数种族和少数民族患者的疾病负担过重，危重患者的结局更差。 病尤其是黑人患者不仅患上急性呼吸道疾病的风险更高， 衰竭（ARF）和败血症，但也增加了死亡风险。ARF或脓毒症患者通常接受 在重症监护室（ICU）或普通内科病房进行医疗护理。一般来说，大多数人会认为 分流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 影响分诊决定能力紧张，定义为护理单位提供高质量医疗服务的能力有限 由于资源而对患者的护理已经与健康护理决策相关联。能力紧张是一种 重要的系统现象，因为它是（1）常见的所有急性医疗保健系统，（2）容易察觉 由医疗保健提供者，和（3）与不良的临床结果。尽管越来越多的文献表明 能力紧张在医疗保健业务中的作用，以前没有研究旨在确定 种族和少数民族患者的能力紧张、差异和临床结局之间的关系。 确定重症患者的能力紧张和医疗差异的作用至关重要， 描述能力紧张、危重疾病和患者结局之间的关系，（2）制定 理解医院内操作如何有助于发展差异的框架， （3）为旨在减少全球化的实施举措确定系统级目标， 医疗差距。这种分析对于重新形成对性别差异的共同理解至关重要。 通过强调院内危险因素对危重疾病发展的重要性，这将 与目前主要关注医院间因素的解释相反， 和低绩效的重症监护中心。 本研究的目的是（1）了解医院范围内的能力紧张，ICU分诊， ARF和脓毒症患者人群中的种族/民族差异，以及（2）评估差异 ARF和脓毒症患者中ICU分诊获益的人种/种族之间的差异。首先，我打算利用 多变量建模技术，以确定重要的社会人口变量并评估影响 各种能力应变指标和患者种族/民族之间的修改。接下来，我的目标是利用因果效应 评估不同患者种族/民族之间ICU受益的方法。 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）评估紧急情况下患者临床护理过程中容量应变的累积影响 科室、ICU和病房，（2）评估由不同分诊模式导致的经济差异，以及（3） 制定实施干预措施，以减轻以患者为中心的结果的差异， 整个医院的能力紧张。

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.