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方面存在根本差距， 美国的长寿：美国某些州和县的人寿命分别为3.5岁（男性）和4.6岁 （女性）低于健康状况较好的州。这种差距的持续存在，甚至扩大， 时间是美国卫生系统的一个重要问题。这些地理差异与 随着疾病负担的增加，卫生保健系统的卫生支出增加， 与其他工业化国家相比，健康和寿命方面存在差距。本申请的目的 是确定观察到的地理差异的机制，并澄清临床的作用， 非临床相关因素在其中起作用。我们预计，这些地理差异可以观察到， 个人医疗保险轨迹和5%医疗保险数据集的大小和范围， 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，我们将测试四种情况，这些差异如何反映在健康方面。 从医疗保险数据中提取的指标：预期寿命较低的地区疾病率较高， 发生率（场景1）、更差的患者生存率（场景2）、更高的多发病率（场景3）和/或更差 65岁的个体的健康状态（即，在进入医疗保险系统时）（场景#4）。在目标1中， 将测试每种情景（或其组合）在多大程度上可以解释观察到的地理差异， mortality.我们将通过每一个项目，确定造成健康差距最大的具体疾病， 需要研究的场景。在目标2中，我们将确定临床相关特征，如使用特定的 治疗、治疗选择和治疗依从性、筛查和诊断程序的使用 （特别是对于早期诊断）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，以及获得和护理质量的措施（从5%-医疗保险 数据）影响目标2中确定的临床指标，作为地理差异的决定因素。结果将 提供有关诊所和非诊所相关障碍的新知识，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。建议的结果 这项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，优化医疗资源的分配，重点是贫困社区， 改善医疗保健标准，以减缓或阻止美国健康差距的扩大。

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.