Racial and Ethnic Health Disparities Due to Ambulance Diversion

 描述（由申请人提供）：2007年，医学研究所（IOM）将救护车分流（AD），即急诊室（ED）暂时关闭的做法描述为“与高质量医疗服务相对立”，并呼吁“消除”。然而，AD仍然存在，在2003年最后一次公布的调查中，45%的ED和70%的城市ED报告AD。AD与较高的死亡率、延迟治疗和其他不良结局相关。迄今尚未审查，AD有可能加剧种族/民族和收入的不平等。AD还可能增加医疗费用。然而，目前关于AD影响的文献是基于方便抽样的数据，并且受到缺乏实验证据的限制。2009年1月1日，马萨诸塞州成为第一个，也是迄今为止唯一一个禁止AD的州。将国家实施的禁令视为自然实验，我们建议估计AD对获取，结果和成本的因果影响，重点关注种族/民族和收入的潜在差异效应。 为了更好地了解救护车的使用和AD的整体病人护理的环境中，我们将开发一个全国纵向数据库的救护车使用的医疗保险管理数据的基础上。使用纵向患者记录，这些数据将更适合于检查救护车使用的决定因素，结果以及AD对不同患者的影响。 我们将重点关注患有慢性心血管或肺部疾病的老年人。我们将确定一个分层随机样本的所有医疗保险受益人年龄在66岁或以上（N= 1，000，000）的国家队列，从马萨诸塞州过采样，并获得所有医疗保健利用的数据，包括救护车和艾德访问，从2006年至2012年。考虑到居住地在检查救护车和艾德使用方面的重要性，将按人种/种族和居住地邮政编码对该样本进行分层，以比较来自同一地区的不同患者。对于波士顿居民的子集（波士顿队列），我们将合并2006-2012年波士顿紧急医疗服务（EMS）的数据，以获得EMS特定的结局指标。我们的具体目标是评估：（1）救护车使用和依赖的发生率，（2）救护车运输结果的种族/民族和收入差异，以及（3）马萨诸塞州AD禁令对救护车运输和其他不由救护车运输的艾德患者的影响。 医学研究所强调环管系统做法的研究和知识基础“有限”。使用全国范围的新数据，这项研究将为这一证据基础做出重大贡献，并为AD的公共政策提供信息，不仅涉及其对临床结局的影响，还涉及其对差异的影响。

 DESCRIPTION (provided by applicant): In 2007, the Institute of Medicine (IOM) characterized ambulance diversion (AD), the practice by which Emergency Departments (EDs) are temporarily closed, as "antithetical to quality medical care" and called for its "elimination". Nevertheless, A persists, with 45% of EDs and 70% of urban EDs reporting AD in the last published survey in 2003. AD has been associated with higher mortality, delayed treatment, and other adverse outcomes. Not examined hitherto, AD has the potential to exacerbate disparities by race/ethnicity and income. AD may also increase healthcare costs. However, the current literature on the impact of AD is based on data from convenience sampling and is limited by a dearth of experimental evidence. On 1/1/2009, Massachusetts became the first, and to date only, state to ban AD. Treating the state-imposed ban as a natural experiment, we propose to estimate the causal impact of AD on access, outcomes, and cost, focusing on the potentially differential effects by race/ethnicity and income. To better understand ambulance use and AD within the milieu of overall patient care, we will develop a national longitudinal database of ambulance use based on Medicare administrative data. Using longitudinal patient records, this data will be better suited to examine the determinants of ambulance use, outcomes, and the impact of AD across diverse patients. We will focus on older adults with a chronic cardiovascular or pulmonary condition. We will identify a national cohort of a stratified random sample of all Medicare beneficiaries aged 66 or older (N=1,000,000), with an oversample from Massachusetts, and obtain data on all healthcare utilization, including ambulance and ED visits, from 2006-2012. Given the primacy of residential location in examining ambulance and ED use, this sample will be stratified by race/ethnicity and residence zip code to enable comparison of diverse patients from the same area. For the subset of Boston residents (Boston cohort) we will merge data from the Boston Emergency Medical Services (EMS) from 2006-2012 for EMS-specific outcome measures. Our specific aims are to evaluate: (1) incidence of ambulance use and reliance, (2) differences by race/ethnicity and income in ambulance transport outcomes, and (3) impact of Massachusetts AD ban on outcomes of ambulance transport and other ED patients not transported by ambulance. The Institute of Medicine (IOM) has highlighted the "limited" research and knowledge base of EMS practices. Using novel data with national scope, this study will make significant contributions to this evidence base and inform public policy on AD regarding not only its impact on clinical outcomes, but also, its impact on disparities.