Understanding Variation in Treatment Intensity with Lower Extremity PAD

描述（由申请人提供）：在外科培训的早期，我发现自己的职业不仅会影响临床手术，还会影响医疗保健提供方式等更广泛的问题，这一想法非常有吸引力。因此，在外科培训期间，我获得了VA成果研究特别奖学金的资助，完成了两年的卫生服务研究培训，并同时获得了达特茅斯学院（TDI）的评估临床科学硕士学位。现在，作为达特茅斯大学血管外科的助理教授，我有一些研究经验，特别是在使用观察数据集来测量和预测手术风险方面。然而，我相信这个奖项将帮助我成长并实现重要的短期和长期目标，以建立终身的研究生涯。首先，就短期目标而言，该奖项将扩大我测量下肢外周动脉疾病（PAD）患者治疗变化效果的能力。其次，我的长期目标是成为血管预后研究的领导者，重点是设计临床途径和健康政策，旨在帮助患者做出最佳治疗选择。我研究生涯的最终目标将是确保血管疾病患者充分了解不同治疗策略的风险和益处，以便他们能够做出明智的治疗选择。我的职业发展计划中的三个关键要素将促使我努力实现这些目标。首先，通过高级观察统计方法的课程学习，我将确保我加强自己在下肢PAD的竞争治疗和策略中进行高质量比较有效性研究的能力。其次，通过成本分析课程，我将在医疗成本测量方面发展新的专业知识。第三，我将使用基于项目的学习，以确保我的职业发展计划的教学元素转化为行动。出于三个原因，TDI为我的研究提供了一个理想的环境。首先，20多年来，TDI一直被公认为研究卫生保健提供和有效性的国家领导者。TDI在评估医疗服务提供和质量的地区差异、结果分析和共同决策方面产生了国家领导者。其次，我很幸运地得到了TDI的一位领导者埃利奥特·费舍尔博士的指导。从2002年我作为VA成果研究员开始他就一直是我的导师，通过我们最近在测量地区差异方面的努力。第三，TDI与新英格兰血管研究小组建立了密切的关系，这是一个以达特茅斯大学血管外科为中心的区域质量改进倡议。VSGNE已成为我们将临床数据集与管理数据联系起来的试点工作，以及用临床数据改进和测试我们的管理预测模型的平台。我的研究项目将检查血管治疗强度的变化对pad特异性结果的影响。下肢外周动脉疾病（PAD）影响了超过1200万美国人，在美国每年导致近10万例主要截肢（膝盖以上或膝盖以下）。然而，由于患者居住的地方不同，PAD导致截肢的风险相差10倍。达特茅斯卫生保健地图集的研究将截肢的一些地区差异归因于患者层面的因素，报告称黑人和低社会经济地位（SES）的截肢率高出五倍。然而，这种截肢率的显著差异不能仅仅由患者因素来解释；向这些患者提供的医疗保健服务也有很大差异。我们的初步工作显示相当大的差异在血管护理的强度接受病人在一年前，他们接受主要的下肢截肢。这些差异表明，在一些地区，提供的血管护理太少了。在其他地区，非常密集的血管护理，积极使用侵入性血运重建术，可能不一定能为患者带来更好的结果。努力改善对PAD患者的血管护理需要更好地了解护理强度的变化及其与PAD特异性结局的关系。在本提案中，我将描述下肢PAD治疗的变化，探讨这种变化的决定因素，并研究血管护理强度与PAD相关结果的关系。该项目将为我未来的研究提供信息，旨在更好地针对下肢PAD患者使用血管护理以获得最佳结果。

DESCRIPTION (provided by applicant): Early in my surgical training, I found the thought of having a career that affects not only clinical surgery, but also broader issues in the way health care is delivered, to be very appealing. Therefore, during surgical training, I received funding for a VA Special Fellowship in Outcomes Research to complete two years of training in health services research, and concurrently obtained a Master's Degree in Evaluative Clinical Sciences from The Dartmouth Institute (TDI). Now, as an assistant professor at Dartmouth in vascular surgery, I have some research experience, especially in the use of observational datasets to measure and predict surgical risk. However, I believe that this Award will help me to grow and achieve important short and long-term goals in building a lifelong research career. First, in terms of short term goals, this Award will expand my ability to measure the effects of variation in treatment in patients with lower extremity peripheral arterial disease (PAD). Second, my long term goal is to become a leader in vascular outcomes research, with a focus on designing clinical pathways and health policy aimed at helping patients make the best treatment choices. The ultimate goal of my research career will be to ensure that patients with vascular disease are well informed about the risks and benefits of different treatment strategies, so that they can make well-informed treatment choices. Three key elements of my career development plan will foster my efforts towards achieving these goals. First, through coursework in advanced observational statistical methods, I will ensure that I strengthen my ability to perform high-quality comparative effectiveness studies of competing treatments and strategies in lower extremity PAD. Second, through coursework in cost analysis, I will develop new expertise in cost measurement in health care. And third, I will use project-based learning to ensure that the didactic elements of my career development plan translate into action. For three reasons, TDI represents an ideal environment to pursue my research agenda. First, for over 20 years, TDI has been recognized as a national leader in studying health care delivery and effectiveness. TDI has produced national leaders in the evaluation of regional variation in the delivery and quality of care, outcomes analysis, and shared-decision-making. Second, I am fortunate to have the mentorship of one of TDI's leaders, Dr. Elliott Fisher. He has served as a mentor since my time as a VA Outcomes Fellow in 2002, continually through our recent efforts in measuring regional variation. And, third, TDI has developed a close relationship with the Vascular Study Group of New England, a regional quality improvement initiative centered at the Section of Vascular Surgery at Dartmouth. The VSGNE has served as a platform for piloting our work in linking clinical datasets to administrative data, as well as refining and testing our administrative prediction models with clinical data. My research project will examine the effect of variation in vascular treatment intensity on PAD-specific outcomes. Lower extremity peripheral arterial disease (PAD) affects over 12 million Americans, and results in nearly 100,000 major amputations (above or below-knee) annually in the United States. However, the risk of amputation from PAD varies ten-fold, depending on where patients reside. Research in the Dartmouth Atlas of Health Care has attributed some of these regional differences in amputation to patient-level factors, reporting five-fold higher amputation rates among blacks and those of low socioeconomic status (SES). However, such significant variation in amputation rates cannot be explained solely by patient factors; health care delivery to these patients varies significantly as well. Our preliminary work shows sizeable disparities in the intensity of vascular care received by patients in the year before they undergo major lower extremity amputation. These differences suggest that in some regions, far too little vascular care is being provided. In other regions, very intensive vascular care, with aggressive use of invasive revascularization procedures, may not necessarily translate into better outcomes for patients. Efforts to improve vascular care for patients with PAD will require better knowledge of the variation in intensity of care and its relationship to PAD-specific outcomes. In this proposal, I will characterize variation in the treatment of lower extremity PAD, explore the determinants of this variation, and study the relationship of intensity of vascular care to PAD-related outcomes. This project will inform my future research, aimed at better targeting the use of vascular care to achieve optimal outcomes in patients with lower extremity PAD. PUBLIC HEALTH RELEVANCE: The treatment intensity of patients with lower extremity peripheral arterial disease varies widely. A better understanding of the determinants of this variation, as well as the relationship between intensity of care and patient outcomes, will guide efforts to improve vascular care for all Americans with peripheral arterial disease.