Understanding Quality and Equity in Wheelchairs for Veterans

描述（由申请人提供）： 项目摘要/摘要轮椅使退伍军人能够参与他们原本可能无法参与的家庭、就业和社交活动，从而提高他们的生活质量（QOL）。尽管退伍军人事务部努力消除向所有退伍军人提供高质量轮椅的财政和其他障碍，但初步证据表明，为弱势群体（例如，少数民族/种族，较低的社会经济地位）脊髓损伤（SCI）或截肢（AL）的退伍军人。这一发现是令人担忧的，因为接受低质量轮椅的患者可能有不良生理，心理，经济和生活质量结果的风险。越来越多的研究表明，患者的心理社会特征（例如，医疗不信任、感知歧视、控制点）和提供者因素（例如，人口统计学和培训）与医疗保健过程和结果的差异有关。然而，对于SCI或AL的退伍军人，迄今为止还没有研究检查（a）哪些患者和提供者因素与高质量轮椅的处方相关，以及（B）这些因素如何与轮椅质量和患者结局相关。对使用轮椅作为主要活动来源的SCI或AL退伍军人进行的拟议横断面、多中心研究旨在确定：（1）患者人口统计学（例如，种族，SES）和社会心理特征（例如，医疗不信任，歧视经历）和提供者因素（例如，（2）轮椅质量与关键患者结局相关，包括对医疗护理的满意度、QOL、轮椅活动量以及参与社会和工作相关活动;（3）患者和提供者因素与关键患者结果独立相关，包括对医疗护理的满意度，QOL，轮椅活动量，参与;以及（4）患者和提供者因素与患者结果的关联可以通过轮椅质量的差异来解释。将从宾夕法尼亚州费城、俄亥俄州克利夫兰、弗吉尼亚州里士满和纽约州布朗克斯的弗吉尼亚州医疗中心招募通过退伍军人管理局规定使用轮椅的SCI或AL退伍军人，参与访谈，以评估其人口统计学特征、健康信息、心理社会特征（包括歧视经历、感知的种族主义、医疗不信任、自我形象、焦虑/抑郁、健康信念、健康素养，和沟通）和健康相关的结果（包括轮椅技能，满意度，QOL，参与）。我们还将使用数据记录设备评估轮椅活动量，并通过其品牌和型号确定轮椅质量。还将从参与为研究受试者提供轮椅的所有医疗保健提供者处收集数据。供应商因素将包括人口统计学（例如，种族/民族、年龄、性别）和专业（即，MD/OT/PT）。对于职业和物理治疗师，我们将确定他们是否获得北美康复工程和辅助技术协会的认证。自完成医疗培训以来的实践年数，在其职业生涯中规定的椅子数量，每个提供者在轮椅提供过程中扮演的角色，以及他们在过去3年中获得的与轮椅相关的继续医学教育（CME）学分和/或教育学分单位（ECU）的数量也将进行评估。了解拟议的患者特征和供应商因素之间的关联是制定针对患者和供应商的定制干预措施的重要一步，以提高退伍军人轮椅服务的质量和公平性。 公共卫生相关性： 退伍军人事务部（VA）为大约42，000名SCI退伍军人和40，000多名截肢退伍军人（AL）提供轮椅。尽管退伍军人事务部努力消除向所有需要轮椅的退伍军人提供轮椅的财政和其他障碍，但初步证据表明，向少数民族和低收入SCI或AL退伍军人提供的轮椅质量存在差异。拟议项目将向退伍军人事务部提供有关向SCI或AL退伍军人提供轮椅的质量和公平性的重要信息，它将确定与提供轮椅有关的病人和提供者因素。由于SCI和AL退伍军人被认为是特殊的残疾人群，识别和理解这些因素是制定干预措施以提高向所有残疾退伍军人提供轮椅的质量和公平性的关键第一步。

DESCRIPTION (provided by applicant): PROJECT SUMMARY/ABSTRACT Wheelchairs enable Veterans to participate in home, employment, and social activities that might otherwise be inaccessible to them, thereby improving their quality of life (QOL). Despite VA's efforts to remove financial and other barriers to the provision of high quality wheelchairs to all Veterans, preliminary evidence suggests that disparities exist in the quality of wheelchairs prescribed to vulnerable (e.g., minority race/ethnicity, lower socioeconomic status) Veterans with Spinal Cord Injury (SCI) or amputated limbs (AL). This finding is concerning because patients who receive lower quality wheelchairs may be at risk for adverse physical, psychological, economic, and QOL outcomes. Mounting research demonstrates that patient psychosocial characteristics (e.g., medical mistrust, perceived discrimination, locus of control) and provider factors (e.g., demographics and training) are associated with disparities in healthcare processes and outcomes. However, for Veterans with SCI or AL, no studies to date have examined (a) what patient and provider factors are associated with the prescription of high quality wheelchairs, and (b) how these factors are associated with wheelchair quality and patient outcomes. The proposed cross-sectional, multi-site study of Veterans with SCI or AL who use a wheelchair as their primary source of mobility aims to determine whether: (1) patient demographic (e.g., race, SES) and psychosocial characteristics (e.g., medical mistrust, experience of discrimination) and provider factors (e.g., years of practice, certification, demographics) are associated with wheelchair quality; (2) wheelchair quality is associated with key patient outcomes, including satisfaction with medical care, QOL, amount of wheelchair activity, and participation in social and work-related activities; (3) patient and provider factors are independently associated with key patient outcomes including satisfaction with medical care, QOL, amount of wheelchair activity, and participation; and (4) the association of patient and provider factors with patient outcomes is explained by differences in wheelchair quality. Veterans with SCI or AL, who were prescribed their wheelchairs through the VA, will be recruited from the Philadelphia, PA, Cleveland, OH, Richmond, VA, and Bronx, NY VA Medical Centers to participate in an interview to assess their demographic characteristics, health information, psychosocial characteristics (including, experience of discrimination, perceived racism, medical mistrust, self-image, anxiety/depression, health beliefs, health literacy, and communication) and health-related outcomes (including wheelchair skills, satisfaction, QOL, participation). We will also assess amount of wheelchair activity using data logging devices, and determine wheelchair quality by its make and model. Data will also be collected from all health care providers involved in wheelchair provision for study participants. Provider factors will include demographics (e.g., race/ethnicity, age, gender), and specialty (i.e., MD/OT/PT). For Occupational and Physical Therapists, we will determine if they are certified by the Rehabilitation Engineering and Assistive Technology Society of North America. Years of practice since completion of medical training, number of chairs prescribed over the span of their career, what role each provider plays in the wheelchair provision process, as well as the number of continuing medical education (CME) credits and/or educational credit units (ECU) they have obtained in the past 3 years related specifically to wheelchairs, will also be assessed. Understanding the associations among the proposed patient characteristics and provider factors is an essential step toward developing tailored interventions, aimed at patients and providers, to improve the quality and equity of wheelchair service delivery for Veterans. PUBLIC HEALTH RELEVANCE: PROJECT NARRATIVE The Department of Veterans Affairs (VA) provides wheelchairs to about 42,000 Veterans with SCI and more than 40,000 Veterans with amputated limbs (AL). Despite VA's efforts to remove financial and other barriers to the provision of wheelchairs to all Veterans who need them, preliminary evidence suggests that disparities exist in the quality of wheelchairs prescribed to racial minorities and low income Veterans with SCI or AL. The proposed project will provide important information to the VA about the quality and equity of wheelchairs provided to Veterans with SCI or AL, and it will identify the patient and provider factors associated with wheelchair provision. Because Veterans with SCI and AL are considered special disability populations, identifying and understanding these factors is a critical first step to developing interventions to increase the quality and equity of wheelchairs provided to all disabled Veterans.