Understanding Variation in Treatment Intensity with Lower Extremity PAD

了解下肢 PAD 治疗强度的变化

• 批准号: 8267739
• 负责人: Philip P Goodney
• 金额: $ 13.99万
• 依托单位: DARTMOUTH COLLEGE
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-09-15 至 2015-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8267739
• 关键词: Affect; African American; American; Amputation; Atlases; Award; Benefits and Risks; Blood Vessels; Bypass; Care given by nurses; Caring; Characteristics; Clinical; Clinical Data; Clinical Pathways; Clinical Sciences; Comorbidity; Consultations; Cost Analysis; Data; Data Set; Development Plans; Effectiveness; Elements; Ensure; Environment; Evaluation; Expenditure; Fellowship; Fostering; Funding; Gender; Goals; Health Care Delivery Study; Health Policy; Health Services Research; Healthcare; Hospitals; Image; Independent Living; Institutes; Intervention; Knee; Knowledge; Learning; Length of Stay; Link; Lower Extremity; Master' s Degree; Measurement; Measures; Medical; Medicare; Medicare claim; Mentors; Mentorship; Modeling; New England; Operative Surgical Procedures; Outcome; Outcomes Research; Patient Care; Patients; Peripheral arterial disease; Procedures; Provider; Quality of Care; Race; Reporting; Research; Research Project Grants; Risk; Role; Socioeconomic Status; Specialist; Statistical Methods; System; Testing; Time; Training; Translating; United States; Variant; Vascular Diseases; Work; base; career; career development; comparative effectiveness; cost; design; experience; health care delivery; improved; low socioeconomic status; patient population; population based; professor; regional difference; secondary outcome; shared decision making; treatment strategy

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.

在我的手术训练的早期，我发现了一种职业，不仅会影响临床手术，而且会影响医疗保健提供的更大问题，这非常吸引人。因此，在手术培训期间，我获得了VA的成果研究的资金，以完成两年的卫生服务研究培训，并同时获得了达特茅斯研究所（TDI）的评估临床科学硕士学位。现在，作为达特茅斯（Dartmouth）的助理教授，我有一些研究经验，尤其是在使用观察数据集来衡量和预测手术风险方面。但是，我相信该奖项将帮助我成长并实现重要的短期和长期目标，以建立终身研究职业。首先，就短期目标而言，该奖项将扩大我衡量下肢外围动脉疾病（PAD）患者治疗影响的影响的能力。其次，我的长期目标是成为血管结果研究的领导者，重点是设计临床途径和卫生政策，旨在帮助患者做出最佳的治疗选择。我研究生涯的最终目标是确保血管疾病患者对不同治疗策略的风险和好处充分了解，以便他们可以做出明智的治疗选择。 我职业发展计划的三个关键要素将促进我为实现这些目标而努力。首先，通过高级观察统计方法的课程工作，我将确保我加强对下肢竞争治疗和策略进行高质量比较有效性研究的能力。其次，通过成本分析的课程工作，我将在医疗保健方面开发新的成本衡量专业知识。第三，我将使用基于项目的学习来确保我的职业发展计划的教学要素转化为行动。 出于三个原因，TDI代表了追求我的研究议程的理想环境。首先，在20多年来，TDI一直被认为是研究医疗保健提供和有效性的国家领导者。 TDI在评估护理和质量质量，成果分析和共享决策的区域变化方面培养了国家领导者。其次，我很幸运能够得到TDI领导人之一埃利奥特·费舍尔（Elliott Fisher）博士的指导。自从我时代以来，他在2002年担任VA成果研究员以来一直担任导师，这是我们最近在衡量区域变化方面的努力。第三，TDI与新英格兰的血管研究小组建立了密切的关系，新英格兰的血管研究小组是一项以达特茅斯血管手术部分为中心的区域质量改进计划。 VSGNE已成为试点我们将临床数据集链接到管理数据的工作的平台，并使用临床数据来完善和测试我们的管理预测模型。 我的研究项目将研究血管治疗强度对垫特异性结果的变化的影响。下肢外围动脉疾病（PAD）影响超过1200万美国人，每年在美国导致近100,000个主要截肢（膝盖上方或低于膝盖）。但是，板块截肢的风险因患者居住地而异十倍。达特茅斯地图集的研究将截肢区域的一些区域差异归因于患者级别的因素，报告了黑人和低社会经济地位（SES）的截肢率高五倍。 但是，截肢率的这种显着差异不能仅由患者因素来解释。向这些患者提供的医疗保健分娩也有很大差异。我们的初步工作表明，在患者接受重大下肢截肢之前，患者接受的血管护理强度差异很大。这些差异表明，在某些地区，提供了太少的血管护理。在其他地区，通过积极使用侵入性血运重建程序的非常密集的血管护理，不一定会转化为患者更好的预后。 改善PAD患者的血管护理的努力将需要更好地了解护理强度及其与PAD特异性结果的关系。在此提案中，我将表征下肢治疗的差异，探索这种变化的决定因素，并研究血管护理与垫相关结果的强度的关系。该项目将为我的未来研究提供信息，旨在更好地针对使用血管护理以在下肢垫中获得最佳结果。