Modifiable factors in emergent presentation of potentially elective general surgical disease for patients who are insured or insurance-eligible

项目摘要/摘要 我们提议的研究的总体目标是了解为什么拥有医疗保险(或资格 医疗保险)不足以使人们平等地获得选择性外科护理。尽管取得了成功 通过扩大医疗补助和平价医疗法案(ACA)扩大覆盖范围的努力，可能是选择性的 外科护理通常是在紧急情况下才处理的。这些患者往往来自 弱势群体，他们不仅更频繁地出现在紧急普通手术(EGS)中，而且 经历更糟糕的结果和更大的成本。在美国导致这一演示的差异 在与保险地位、种族和收入的总体关系方面得到了很好的描述，但更深入的数据 迫切需要收集和分析，以确定可以为干预提供信息的可修改因素 关于减少这些人口中的紧急情况，特别是在卫生保健覆盖面方面。 即使在拥有全民医疗保健系统的国家，人们在如何能够实际 访问这些服务。 我们最初是在急诊胆囊切除术的背景下研究这个问题的，这是我们最常见的手术之一 EGS病的表现。我们发现，缺乏医疗保险并不是一个主要因素；事实上，86% 我们的患者中有某种类型的保险(29%是私人的，57%是公共的)，许多其他社会因素导致了 紧急手术。我们现在寻求为定义的其他EGS条件详细扩展和探索这一点 由美国创伤外科协会(AAST)使用多阶段混合方法。 我们将1)确定紧急演示文稿的可修改因素，并探索进展轨迹 在融合的混合方法设计中，使用计费数据和电子病历的择期手术与急诊手术， 将定量变量与定性叙述数据相结合，2)识别和量化额外的可修改 来自患者角度的因素，这些因素在使用 探索性顺序设计，使用确定的域对以下各项进行系统审查和荟萃分析 量化数据，以及3)确定哪些或哪些可修改因素将对 未来的干预策略采用马尔可夫模型。 这项提议将利用我们以新颖的方式链接来自多个来源的数据的能力，我们多样化、健壮的 普通外科人群处于医疗补助扩展状态，合作调查员在他们的领域内是专家 纵向数据建模和混合方法研究。有了这些数据，我们就可以建模并了解 影响了尽管覆盖面扩大了，但在获得选择性外科护理的能力方面的持续差距， 并预测哪些因素对差距的影响最大，从而可能产生最大的影响。 通过确定可操作的可修改因素，我们最终将制定有效的干预策略，以防止 择期外科疾病的紧急表现。

PROJECT SUMMARY/ABSTRACT The overall goal of our proposed research is to understand why having health care coverage (or eligibility for health care coverage) is not sufficient to allow equal access to elective surgical care. Despite successful efforts to expand coverage through Medicaid expansion and the Affordable Care Act (ACA), potentially elective surgical care is often not addressed until it becomes an emergency. These patients tend to come from vulnerable populations, who not only present more often for Emergency General Surgery (EGS), but experience worse outcomes and greater costs. The disparities leading to this presentation in the United States have been well-described in terms of overall relationship to insurance status, race and income, but deeper data collection and analysis are desperately needed to identify modifiable factors that can inform interventions around decreasing emergent presentation in these populations, particularly in regard to health care coverage. Even in countries with Universal Health Care systems, disparities are noted in how people are able to actually access those services. We initially studied this problem in the context of emergent cholecystectomy, one of our most common presentations of EGS disease. We found that lack of health care coverage was not a major factor; in fact, 86% of our patients had some type of coverage (29% private, 57% public), and many other social factors led to an emergency operation. We now seek to expand and explore this in detail for the other EGS conditions defined by the American Association for the Surgery of Trauma (AAST) using a multiphase mixed method approach. We will 1) identify modifiable factors for emergent presentation and explore the trajectory of progression to elective versus emergency surgery using billing data and EHR in a convergent mixed-methods design, combining quantitative variables with qualitative narrative data, 2) identify and quantify additional modifiable factors from the patient perspective that are not available in clinical or administrative datasets using an exploratory sequential design, using identified domains to conduct systematic review and meta-analysis for quantitative data, and 3) determine which modifiable factor or factors identified will have the greatest impact for future intervention strategies using Markov modeling. This proposal will leverage our ability to link data from multiple sources in novel ways, our diverse, robust general surgery population in a Medicaid expansion state, and Co-Investigators who are expert in their fields of longitudinal data modeling and mixed methods research. With this data we can model and understand what influences the persistent disparity in the ability to access elective surgical care despite increased coverage, and predict which factors contribute the most to the disparities and thus hold potential for the greatest impact. By identifying actionable modifiable factors, we will ultimately inform effective intervention strategies to prevent emergent presentation of elective surgical disease.