The Impact of Nurse Practitioner Work Environment and Community Characteristics on Acute Care Utilization by Older Adults with Multiple Chronic Conditions

多种慢性病（MCC），定义为同一个人的两种或多种慢性病， 常见和昂贵的任何个人健康状况在美国（美国）。然而，患有MCC的人通常 接受以病情为中心的分散的初级保健，导致重复检查，药物不良事件， 和相互矛盾的医疗建议这种不充分的初级保健导致频繁的急诊室（艾德） 这些慢性疾病恶化的就诊和住院治疗。健康的社会决定因素， 包括低收入和初级保健服务差，进一步加重了患者的MCC负担。各地 在一个国家，特别是在社会经济资源贫乏的社区，很少有医生进入并留在那里。 初级保健，而护士从业人员（NP）的庞大和不断增长的劳动力提供安全，具有成本效益 在这些服务不足的地区提供初级保健。然而，关于初级保健如何 实践可以支持NP满足MCC患者复杂的护理需求。NP护理环境差， 其特点是缺乏对NP实践的支持，临床医生之间的合作，以及组织理解 NP角色，通过职业倦怠和人员流动耗尽组织的财务和人力资源， 挑战NPs为MCC患者提供护理的能力。积极的NP护理环境 为慢性病提供优质护理，并可能有助于减轻贫困社区的负面影响。 通过最佳的团队合作、支持和沟通，了解患者的特征。然而，到目前为止，还没有研究表明， 调查了NP护理环境对社区特征与 对MCC患者的治疗效果。为了填补这一关键的证据空白，本论文将利用现有的 我的导师进行的研究的数据集（R 01 MD 011514 PI：Poghosyan，2016-2022），其中包含 关于六个州的NP护理环境的信息与1）医疗保险索赔（即，患者 特征、艾德就诊和住院），2）根据美国人口普查创建的社会经济地位指数 局数据，和3）初级保健服务区文件表明初级保健服务的可用性。我的目标是 目标1：评估NP护理环境和社区特征（即，社会经济地位 和初级保健可用性）的做法，照顾≥65岁的MCC患者。目标2：调查 护理环境、社区特征与急诊护理利用的关系 (i.e.,艾德利用率和住院率），并确定是否需要治疗 环境调节社区特征和急性护理利用之间的关系。 我将有机会进入哥伦比亚大学的充足的研究基础设施，我得到了一个 杰出的指导团队，在NP劳动力，MCC，多级建模和传播方面具有专业知识， 调查结果。这项研究将为改善社会和经济边缘化老年人的健康提供证据 与MCC一起生活的成年人，是医疗保健研究和质量机构的优先人群。

Multiple chronic conditions (MCCs), defined as two or more chronic conditions in the same person, are more common and costly that any individual health condition in the United States (US). Yet, people with MCCs often receive primary care that is condition-centric and fragmented, leading to duplicative tests, adverse drug events, and conflicting medical advice. Such inadequate primary care leads to frequent emergency department (ED) visits and hospitalizations for exacerbations of these chronic conditions. Social determinants of health, including low income and poor primary care availability, further worsen patients’ burden of MCCs. Across the nation, particularly in communities with poor socioeconomic resources, few physicians enter and stay in primary care while the large and growing workforce of nurse practitioners (NPs) provide safe, cost-effective primary care in these underserved areas. However, there is a gap in evidence regarding how primary care practices can support NPs to meet the complex care needs of people with MCCs. Poor NP care environments, marked by lack of support for NP practice, collegiality between clinicians, and an organizational understanding of the NP role, deplete organizations of financial and human resources through burnout and turnover, challenging NPs’ ability to provide care for people with MCCs. Positive NP care environments are associated with quality care for chronic disease and may help alleviate the negative impact of poor community characteristics on patients through optimal teamwork, support, and communication. Yet, to date, no study has investigated the impact of NP care environment on the relationship between community characteristics and outcomes for people with MCCs. To fill this critical gap in evidence, this dissertation will leverage an existing dataset from a study conducted by my mentor (R01MD011514 PI: Poghosyan, 2016-2022) which contains information on NP care environments across six states merged with 1) Medicare claims (i.e., patient characteristics, ED visits, and hospitalizations), 2) the Socioeconomic Position Index created from US Census Bureau data, and 3) Primary Care Service Area files indicating primary care service availability. My aims are to: Aim 1: Assess NP care environments and community characteristics (i.e., socioeconomic position and primary care availability) of practices caring for patients ≥65 years with MCCs. Aim 2: Investigate the relationship between NP care environment, community characteristics, and acute care utilization (i.e., ED utilization and hospitalizations) among patients ≥65 years with MCCs and determine if care environment moderates the relationship between community characteristics and acute care utilization. I will have access to ample research infrastructure at Columbia University, and I am supported by an exceptional mentorship team with expertise in NP workforce, MCCs, multilevel modelling, and dissemination of findings. This study will produce evidence to improve health for socially and economically marginalized older adults living with MCCs, an Agency for Healthcare Research and Quality priority population.