Comparative Effectiveness of Prehospital and Hospital Emergency Care

描述（由申请人提供）：患有心脏骤停或重大创伤等危急情况的患者通常依赖院前急救医疗服务（EMS）进行救生护理。然而，这种护理的证据基础，特别是因为它涉及到院前和医院环境之间的过渡，是非常有限的。由于缺乏将院前和住院服务联系起来的数据，人们对这些转变知之甚少。如果没有相关数据，许多关于急救系统和方案有效性的重要问题就无法得到回答。 该项目将创建一个数据基础设施，用于比较有效性研究（CER），使用新泽西院前EMS运输的新可用电子患者护理记录，将院前和医院护理联系起来（具体目标1）。这些数据将与所有付款人的出院摘要数据和死亡证明相关联，以支持广泛的患者和系统级干预措施的比较有效性研究，其中院前和医院服务紧密相连。这种联系利用了学术研究人员与新泽西卫生和高级服务部（DHSS）之间的创新伙伴关系，该部门可以获得机密的患者标识符。 数据基础设施将应用于为院外心脏骤停的初始幸存者提供治疗性低温（TH）后临床结局的比较有效性研究（具体目标2）。院外心脏骤停（OHCA）是一项重大的公共卫生挑战，每年影响超过295，000名美国居民。两项小型随机临床试验表明，治疗性低温可以提高OHCA后恢复自主循环的患者的神经系统完整生存率。然而，尽管颁布了使用低温治疗的国家指南，但还没有大规模的研究将这种治疗与通常的常温逮捕后护理进行比较。 该研究将比较接受和未接受TH的OHCA患者在出院时和30天时的神经系统完整生存率。将使用多变量模型调整混杂因素，如患者风险因素、EMS响应时间和进行的院前程序。住院并发症的差异（例如，还将比较癫痫发作、心律失常、休克）和资源使用（ICU总住院时间和天数）。最后，将在AHRQ优先人群中评估获得这一技术的情况。 该项目在创建美国最大的院前/住院数据集方面具有创新性，并进行了TH的首批大规模CER研究。与目前狭义的创伤和心脏事件登记相比，链接的数据库将使研究和监测的范围更加广泛。该项目借鉴了卫生服务研究，卫生政策，急诊医学和EMS业务的高级专家组成的多元化团队的专业知识。 公共卫生相关性：患有心脏骤停或严重创伤等危急情况的患者通常依赖院前急救医疗服务来挽救生命，但这种护理的证据基础非常有限。该项目将在新泽西州创建一个全州范围的数据基础设施，用于将院前数据与医院数据联系起来的比较有效性研究。对院外心脏骤停最初幸存者的低温治疗护理研究将证明这种数据基础设施的价值。

DESCRIPTION (provided by applicant): Patients with critical conditions such as cardiac arrest or major trauma often depend on prehospital emergency medical services (EMS) for life-saving care. Nevertheless, the evidence base for that care, particularly as it relates to transitions between prehospital and hospital settings, is extremely limited. These transitions are poorly understood because data linking prehospital and hospital services are lacking. Without linked data, many important questions about the effectiveness of emergency care systems and protocols cannot be answered. This project will create a data infrastructure for comparative effectiveness research (CER) that bridges prehospital and hospital care using newly available electronic patient care records for prehospital EMS transports in New Jersey (Specific Aim 1). These data will be linked to all-payer hospital discharge abstract data and death certificates to support a wide range of comparative effectiveness studies on patient- and system-level interventions where prehospital and hospital services are tightly connected. The linkage draws on an innovative partnership between academic researchers and the New Jersey Department of Health and Senior Services (DHSS) which has access to confidential patient identifiers. The data infrastructure will be applied to a comparative effectiveness study of clinical outcomes after provision of therapeutic hypothermia (TH) for initial survivors of out-of-hospital cardiac arrest (Specific Aim 2). Out-of-hospital cardiac arrest (OHCA) is a major public health challenge, afflicting over 295,000 US residents annually. Two small randomized clinical trials demonstrated that therapeutic hypothermia can improve neurologically intact survival among patients with restored spontaneous circulation following OHCA. Nevertheless, despite the promulgation of national guidelines for use of hypothermia treatment, there have been no large-scale studies comparing this treatment to usual normothermic post-arrest care. The study will compare rates of neurologically intact survival at discharge and at 30 days between OHCA patients receiving and not receiving TH. Multivariate models will be used to adjust for confounders such as patient risk factors, EMS response times, and prehospital procedures performed. Differences in in-hospital complications (e.g., seizures, arrhythmias, shock) and resource use (overall length of stay and days in the ICU) will also be compared. Finally, access to this technology will be assessed among AHRQ priority populations. This project is innovative in creating one of the largest linked prehospital/hospital data sets in the U.S. and in conducting one of the first large-scale CER studies of TH. The linked database will enable a much wider scope of research and surveillance than is currently possible with narrowly defined trauma and cardiac event registries. The project draws on the expertise of a diverse team of senior experts in health services research, health policy, emergency medicine, and EMS operations. PUBLIC HEALTH RELEVANCE: Patients with critical conditions such as cardiac arrest or major trauma often depend on prehospital emergency medical services for life-saving care, but the evidence base for that care is extremely limited. This project will create a statewide data infrastructure in NJ for comparative effectiveness research linking prehospital to hospital data. A study of therapeutic hypothermia care for initial survivors of out-of-hospital cardiac arrest will demonstrate the value of this data infrastructure.