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Expansion of Percutaneous Coronary Intervention in Outpatient and Inpatient Settings: Quantifying the Differential Impact Between Disadvantaged and Non-Disadvantaged Communities

经皮冠状动脉介入治疗在门诊和住院环境中的扩展：量化弱势群体和非弱势群体之间的差异影响

基本信息

批准号：
10660869
负责人：
Renee Yuen-Jan Hsia
金额：
$ 62.75万
依托单位：
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
依托单位国家：
美国
项目类别：
财政年份：
2016
资助国家：
美国
起止时间：
2016-07-01 至 2027-06-30
项目状态：
未结题

项目摘要

Project Summary/Abstract Expansion of Percutaneous Coronary Intervention in Outpatient and Inpatient Settings: Quantifying the Differential Impact Between Disadvantaged and Non-Disadvantaged Communities Technology in medicine has often been deployed without explicit attention to disadvantaged populations, with the idea that “a rising tide lifts all boats.” Yet it is now clear that this assumption has not held true, particularly in the field of cardiac care and availability of percutaneous coronary intervention (PCI). Racial and ethnic minorities, low-income individuals, and the uninsured experience persistent and even widening inequalities in access, treatment, and outcomes. Unfortunately, the literature has focused primarily on discrimination at the individual or institutional level. Our long-term goal is to identify system-level pathways in cardiac care that widen disparities between disadvantaged and non-disadvantaged communities and patients. Our central hypothesis is that that the current pattern of PCI growth has differentially affected disadvantaged versus non-disadvantaged communities, and that studying these communities separately allows us to unmask differences that could otherwise be undetected when looking at the average effect. Using PCI expansion as an identification strategy along with 10 years of patient-level data from California, we propose to test the hypothesis that the growth of outpatient and inpatient PCI has: (Aim 1) increased the likelihood of higher-risk or inappropriate patients receiving PCI in non-disadvantaged relative to disadvantaged communities; (Aim 2) changed patient distribution to low-quality facilities in disadvantaged versus advantaged communities; and (Aim 3) widened the health disparity gap between patients in disadvantaged and non- disadvantaged communities through changes in patient profile and/or the quality of PCI facility. This study is innovative because it proposes: a) a longitudinal, population-based approach to study all PCIs done in both outpatient and inpatient settings, not relying solely on hospital-based PCI or PCI registries; b) a multi-level (individual, hospital, and community) approach to understand differential experiences of technology expansion for patients, facilities, and communities; and c) use a structural racism and discrimination lens to focus on the built environment, which present an intervenable target. Findings from our research could inform interventions such as local, state, or even federal policy changes. The current trend appears to be toward allowing as many hospitals as possible to become PCI- capable, with active legislation (e.g., California AB 370, New Jersey A1176). Current policies and legislation do not consider impact on equity nor do they incorporate explicit quality metrics. Examples of potential policy changes include reforms to legal and regulatory changes regarding licensing, credentialing, reimbursement, and liability; revising definitional requirements of a PCI center; or certificate of need regulations that thoughtfully incorporate population-based equity measures for health disparity populations.

项目总结/摘要经皮冠状动脉介入治疗在门诊和住院患者中的扩展：残疾人社区和非残疾人社区之间的不同影响医疗技术的使用往往没有明确关注弱势群体，人口，有一个想法，“涨潮举起所有的船。”然而，现在很明显，这一假设并不成立这是事实，特别是在心脏护理和经皮冠状动脉介入治疗（PCI）的可用性领域。种族和少数民族，低收入个人，以及没有保险的经历持续，甚至扩大在获取、治疗和结果方面的不平等。不幸的是，文献主要集中在个人或机构层面的歧视。我们的长期目标是确定系统级途径，心脏护理扩大了弱势和非弱势社区和患者之间的差距。我们的中心假设是，目前的PCI增长模式对弱势群体与非弱势群体，分别研究这些群体，允许我们揭露差异，否则在观察平均效应时可能无法检测到。使用 PCI扩展作为一种识别策略，沿着来自加州的10年患者水平数据，我们建议检验以下假设：门诊和住院PCI的增长：（目的1）增加了相对于弱势患者，非弱势患者接受PCI的风险较高或不适当患者的可能性（目标2）将患者分布改为弱势群体中的低质量设施，（3）扩大了弱势群体和非弱势群体患者之间的健康差距。通过患者特征和/或PCI设施质量的变化，改善弱势群体的健康状况。这项研究是创新的，因为它提出：a）一个纵向的，基于人口的方法来研究所有在门诊和住院患者中进行PCI，而不仅仅依赖于基于医院的PCI或PCI登记; B）多层次（个人，医院和社区）的方法来了解不同的经验，为患者、设施和社区扩展技术;以及c）使用结构性种族主义，识别透镜集中在建筑环境，这是一个可干预的目标。我们的研究结果可以为地方、州甚至联邦政策等干预措施提供信息变化目前的趋势似乎是允许尽可能多的医院成为PCI- 有能力，有积极的立法（例如，加州AB 370，新泽西A1176）。目前的政策和法律不考虑对公平的影响，也不纳入明确的质量指标。潜在政策的例子这些变化包括对有关许可、资格认证、报销和责任;修改PCI中心的定义要求;或需要法规的证书，针对健康不平等的人口，考虑采用基于人口的公平措施。