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、就业和社会活动，从而提高他们的生活质量(QOL)。尽管退伍军人管理局努力消除向所有退伍军人提供高质量轮椅的财务和其他障碍，但初步证据表明，为患有脊髓损伤(SCI)或截肢(AL)的退伍军人开给弱势群体(例如，少数族裔/族裔、较低的社会经济地位)的轮椅的质量存在差异。这一发现令人担忧，因为接受较低质量轮椅治疗的患者可能面临身体、心理、经济和生活质量不良后果的风险。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、感知到的歧视、控制点)和提供者因素(例如，人口统计和培训)与医疗过程和结果的差异有关。然而，对于患有脊髓损伤或急性白血病的退伍军人，到目前为止还没有研究调查(A)患者和提供者的因素与高质量轮椅处方的关系，以及(B)这些因素与轮椅质量和患者预后的关系。拟议的对使用轮椅作为主要活动来源的SCI或AL退伍军人的横断面、多地点研究旨在确定：(1)患者人口统计(例如，种族、社会经济地位)和心理社会特征(例如，医疗不信任、歧视经历)和提供者因素(例如，执业年限、认证、人口统计)是否与轮椅质量有关；(2)轮椅质量与关键患者结果相关，包括对医疗保健、生活质量、轮椅活动量以及参与社交和工作相关活动的满意度；(3)患者和提供者因素与关键的患者结果独立相关，包括对医疗服务的满意度、生活质量、轮椅活动量和参与度；以及(4)患者和提供者因素与患者结果的关联通过轮椅质量的差异来解释。患有SCI或AL的退伍军人将从宾夕法尼亚州费城、俄亥俄州克利夫兰、俄亥俄州里士满和纽约退伍军人医疗中心布朗克斯招募轮椅，参加面试，以评估他们的人口统计特征、健康信息、心理社会特征(包括歧视经历、感知到的种族主义、医疗不信任、自我形象、焦虑/抑郁、健康信念、健康素养和沟通)以及与健康相关的结果(包括轮椅技能、满意度、生活质量、参与)。我们还将使用数据记录设备评估轮椅活动量，并根据轮椅的制造和型号来确定轮椅的质量。还将从所有参与为研究参与者提供轮椅的医疗保健提供者那里收集数据。提供者因素将包括人口统计(例如，种族/民族、年龄、性别)和专业(例如，MD/OT/PT)。对于职业和物理治疗师，我们将确定他们是否获得了北美康复工程和辅助技术协会的认证。还将评估自完成医学培训以来的执业年限、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年中获得的专门与轮椅有关的持续医学教育学分和/或教育学分单位的数量。了解拟议的患者特征和提供者因素之间的关联是制定针对患者和提供者的量身定制干预措施的关键一步，以提高为退伍军人提供轮椅服务的质量和公平性。

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.