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

多重慢性病(MCC)，定义为同一人中的两种或两种以上慢性病， 在美国，任何个人的健康状况都是常见且昂贵的。然而，患有MCC的人经常 接受以病情为中心和支离破碎的初级保健，导致重复测试、不良药物事件、 以及相互矛盾的医疗建议。初级保健不足导致急诊科(ED)频繁 因这些慢性疾病的恶化而就诊和住院。健康的社会决定因素， 包括低收入和较差的初级保健可获得性，进一步加重了患者的MCC负担。在世界各地 在全国，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医院 初级保健，而数量庞大且不断增长的护士从业人员(NP)提供安全、经济高效的服务 在这些服务不足的地区开展初级保健。然而，关于初级保健如何 实践可以支持NPS满足MCC患者的复杂护理需求。糟糕的NP护理环境， 缺乏对NP实践的支持、临床医生之间的合作以及对组织的理解 本国工作人员的作用，通过耗尽和更替耗尽组织的财政和人力资源， 挑战NPS为MCC患者提供护理的能力。积极的NP护理环境与 为慢性病提供高质量的护理，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，改善患者的特点。然而，到目前为止，还没有研究表明 探讨社区护理环境对社区特征与生活质量关系的影响。 对患有MCC的人的结果。为了填补这一关键的证据空白，本论文将利用现有的 来自我的导师(R01MD011514 PI：Poghosyan，2016-2022)的研究数据集，其中包含 有关六个州的NP护理环境的信息与1)联邦医疗保险索赔(即患者 特征、急诊室就诊和住院)，2)根据美国人口普查创建的社会经济地位指数 局数据，以及3)表明初级保健服务可获得性的初级保健服务区文件。我的目标是 目标1：评估社区护理环境和社区特征(即社会经济地位 和初级保健的可获得性)护理65岁的MCC患者的做法≥。目标2：调查 NP护理环境、社区特征与急诊护理利用的关系 (即ED利用率和住院率)在65岁的MCC患者中进行≥，并确定是否提供护理 环境调节社区特征与急性护理利用之间的关系。 我将有权使用哥伦比亚大学充足的研究基础设施，我得到了一个 卓越的指导团队，在NP劳动力、MCC、多层次建模和传播方面具有专业知识 调查结果。这项研究将提供证据，以改善社会和经济上被边缘化的老年人的健康 患有MCC的成年人，卫生保健研究和质量优先人口机构。

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.