Determinants of geographic disparities in mortality and multimorbidity in the U.S.

工作说明书 在理解区域间健康结果差异的性质和 美国人的长寿：美国某些州和县的人活到3.5岁(男性)和4.6岁 (女性)少于健康状况较好的州。这一差距的持续，甚至不断扩大 时间代表着美国卫生系统的一个重要问题。这些地理差异是相关联的 随着疾病负担的增加，卫生保健系统中的卫生支出增加，并展示了 与其他工业化国家相比，中国在健康和寿命方面明显滞后。本应用程序的目标是 是确定所观察到的地理差异背后的机制，并澄清临床和 与临床无关的因素在其中发挥作用。我们预计，这些地理差异可以在 个人联邦医疗保险轨迹，5%联邦医疗保险数据集的规模和范围，并补充 与健康和退休研究相关的医疗保险记录将使我们能够发现这种情况的原因 差距。在这个项目中，我们将测试四种情景，看看这些差异如何反映在健康中 从医疗保险数据中提取的衡量标准：预期寿命较低的地区疾病发病率较高 发病率(场景1)、较差的患者存活率(场景2)、更高的多发病(场景3)和/或更差 65岁个人的健康状况(即进入医疗保险系统时)(情景4)。在目标1中，我们 将测试每种情景(或其组合)在多大程度上能够解释观察到的地理差异 死亡率。我们将通过以下每个项目确定造成健康差距最大的特定疾病 待研究的场景。在目标2中，我们将确定临床相关特征如何使用特定的 治疗、治疗选择和坚持治疗、筛查和诊断程序的使用 (尤其是早期诊断)会影响健康结果，并造成地理差异。 最后，在目标3中，我们将确定非临床相关因素，如社会经济，行为， 环境特征、获得和护理质量措施(5%--医疗保险 数据)对目标2中确定为地理差异决定因素的临床测量产生影响。结果将会是 提供有关临床和非临床相关障碍的新知识，以改善健康和增加 美国表现不佳地区的预期寿命，确定受影响最严重的人口群体，并解释 临床和非临床相关因素在发病率和死亡率趋势中的作用。建议的研究结果 研究将使我们实现长期目标的下一步成为可能：改进疾病策略 预防，优化医疗资源分配，重点是贫困社区和 提高医疗保健标准，以减缓或消除美国日益扩大的健康差距。

Statement of Work There is a fundamental gap in understanding the nature of interregional differences in health outcomes and longevity in the U.S.: people in certain U.S. states and counties live up to 3.5 years (males) and 4.6 years (females) less than in states with better health outcomes. The persistence, and even widening, of this gap over time represents an important problem for the U.S. health system. These geographic disparities are associated with increased burden of disease, increased health expenditures in the health-care system, and showcase an observed lag in health and longevity compared to other industrialized nations. The objective of this application is to identify the mechanisms underlying the observed geographic disparities and clarify the role clinic- and non-clinic-related factors play in them. We expect that these geographic differences can be observed in individual Medicare trajectories and that the size and scope of the 5% Medicare dataset supplemented by Medicare records linked to the Health and Retirement Study will allow us to discover the causes of such disparities. In this project, we will test four scenarios on how these disparities could be reflected in health measures extracted from Medicare data: the regions with lower life expectancy exhibit higher disease incidence (scenario #1), worse patient survival (scenario #2), higher multimorbidity (scenario #3), and/or worse health state of individuals aged 65 (i.e., at time of entry into the Medicare system) (scenario #4). In Aim 1 we will test in what extent each scenario (or their combinations) can explain observed geographic disparities in mortality. We will identify specific diseases that contribute most to health disparities through each of the scenarios to be studied. In Aim 2, we will identify how clinic-related characteristics such as use of specific treatments, treatment choice and adherence to treatment, utilization of screening and diagnostic procedures (especially for early-stage diagnostics) impact the health outcomes and contribute to geographic disparities. Finally, in Aim 3 we will identify how non-clinic-related factors such as socioeconomic, behavioral, environmental characteristics, and access to and quality of care measures (constructed from 5%-Medicare data) impact the clinical measures identified in Aim 2 as determinants of geographic disparities. The results will provide new knowledge about clinic- and non-clinic-related barriers to improvement of health and increase of life expectancy in underperforming U.S. regions, identify the most affected population groups, and explain the role of the clinic and non-clinic-related factors in morbidity and mortality trends. The results of the proposed study will make possible the next step in approaching our long-term goal: to improve strategies of disease prevention, optimize allocations of medical resources with the focus on underprivileged communities and to improve health care standards to slow down or stop the growing gap in health disparities in the U.S.