Addressing social vulnerabilities to prevent hospital readmissions in adults with cardiovascular disease

项目摘要/摘要 这个职业发展奖将使Oanh Nguyen博士成为一名临床医生-研究员，专注于 设计、实施和评估过渡性护理干预措施，以改善 易受伤害的心血管疾病患者。这一奖项将为她提供发展专业知识所需的支持 1)以患者为中心的结果研究的先进方法；2)健康的社会决定因素；以及 3)在真实世界卫生环境中制定、实施和评估干预措施。要实现这些目标 为了实现目标，阮氏组建了一支专家指导团队。她的主要导师伊森·哈姆，医学博士，公共卫生硕士， 在卫生服务研究、PCOR、预测建模、干预开发、 以及培训和指导教师。她的共同导师西蒙·李博士是一位具有专业知识的医学人类学家。 在定性方法、变革与振兴方案和实施科学方面。其他科学顾问包括张松， 博士，高级生物统计学和预测建模技术专家；桑迪普·达斯，医学博士 在实施和评估循证心血管护理提供干预措施方面。 在住院30天内再次入院的成年人高达五分之一，充血性心绞痛的患者 心力衰竭(CHF)和缺血性心脏病(IHD)是风险最高的人群。尽管联邦财政 对心血管疾病和其他疾病的重新入院处罚，这是预防 重新入院仍不得而知。目前的干预措施侧重于改善医疗保健流程，但并没有 解决更深层次的社会脆弱性，如食品和住房不安全或行为健康需求 与较高的再入院风险相关。从她的临床经验和初步研究中了解到这一点。 Nguyen将进行一系列研究：1)开发预测模型，以确定住院患者是否患有 CHF和IHD是再入院的高危人群，并根据疾病严重程度和社会状况对个人进行分层 脆弱性(目标1)；2)对高危患者进行定性访谈，了解患者的观点 关于社会脆弱性如何影响CHF和IHD的医疗康复，以及社区的可接受性- 以应对这些脆弱性为基础的干预措施(目标2)；以及3)开发、试点和评估 除传统医疗外，加强过渡性护理干预，以解决社会脆弱性 需求(目标3)，纳入创新的社会健康信息交换(达拉斯信息交换 门户)。这项研究计划利用了现有的机构资源，包括Halm博士的AHRQ资助的德克萨斯大学 变革与合作组织西南中心；西南科技大学CTSA；以及新的信息技术。这项培训和 研究将成为R01申请全功率随机对照试验的基础，以评估 针对社会和医疗问题的风险分层再入院预防战略的影响 在CHF和IHD中防止再次入院和改善健康结果的脆弱性。

PROJECT SUMMARY/ABSTRACT This career development award will establish Dr. Oanh Nguyen as a clinician-investigator focused on designing, implementing, and evaluating transitional care interventions to improve health outcomes for vulnerable patients with cardiovascular illness. This award will provide support needed to develop her expertise in: 1) advanced methods in patient-centered outcomes research (PCOR); 2) social determinants of health; and 3) intervention development, implementation, and evaluation in real-world health settings. To achieve these goals, Dr. Nguyen has assembled an expert mentorship team. Her primary mentor, Ethan Halm, MD, MPH, has extensive experience in health services research, PCOR, predictive modeling, intervention development, and training and mentoring faculty. Her co-mentor, Simon Lee, PhD is a medical anthropologist with expertise in qualitative methods, PCOR, and implementation science. Additional scientific advisors include Song Zhang, PhD, an expert in advanced biostatistics and predictive modeling techniques; and Sandeep Das, MD, an expert in implementation and evaluation of evidence-based cardiovascular care delivery interventions. Readmission within 30 days of hospitalization occurs in up to 1 in 5 adults, and patients with congestive heart failure (CHF) and ischemic heart disease (IHD) are among those at highest risk. Despite federal financial `readmissions penalties' for cardiovascular and other conditions, the most effective strategy to prevent readmissions remains unknown. Current interventions focus on improving medical care processes, but do not address deeper social vulnerabilities such as food and housing insecurity or behavioral health needs associated with higher readmission risk. Informed by her clinical experience and preliminary studies, Dr. Nguyen will conduct a series of studies to: 1) develop predictive models to identify hospitalized patients with CHF and IHD at high risk for readmission, and to stratify individuals by medical severity and social vulnerabilities (Aim 1); 2) conduct qualitative interviews of high-risk patients to understand patient perspectives on how social vulnerabilities affect medical recovery from CHF and IHD, and on the acceptability of community- based interventions to address these vulnerabilities (Aim 2); and 3) develop, pilot, and assess the feasibility of a transitional care intervention enhanced to address social vulnerabilities in addition to traditional medical needs (Aim 3), incorporating an innovative social-health information exchange (Dallas Information Exchange Portal). This research plan leverages existing institutional resources, including Dr. Halm's AHRQ-funded UT Southwestern (UTSW) Center for PCOR; the UTSW CTSA; and novel information technology. This training and research will form the basis for an R01 application for a fully powered randomized controlled trial to assess the impact of a risk-stratified readmission prevention strategy that addresses both social and medical vulnerabilities to prevent readmissions and improve health outcomes in CHF and IHD.