A theoretical framework and mixed-methods investigation of documentation status as a social determinant of emergency care utilization in adult safety-net patients

项目总结/摘要 背景：作为历史上的少数民族和边缘化人口，无证移民 居住在美国的人在获得医疗保健方面面临着独特和交叉的社会和结构性不平等， 结果。无证移民更有可能报告获得医疗服务的机会有限 保险覆盖率，预防性卫生服务的使用较少，与 他们的对应文件。部分原因是限制获得全面保健服务的排斥性政策 保险覆盖范围，许多无证移民几乎没有选择，只能寻找 寻求替代护理的策略，包括使用安全网急诊科（ED）， 在遇到健康需求时可预防的情况。然而，无证移民仍然主要是 在紧急护理利用文献中代表性不足。艾德用于门诊敏感护理 条件（ACSC）-良好的门诊护理和早期干预可以预防的条件 并发症，住院治疗或更严重的疾病-是一种昂贵的医疗保健形式， 然而，文件与健康的各种社会决定因素相关，包括缺乏保险 作为ACSC的艾德利用的社会决定因素的地位在健康利用中明显缺失 文学方法：我提出了一个深入的调查文件的地位，作为一个社会的决定因素， 安全网环境中ACSC和非ACSC的艾德利用率。除了研究艾德寻求护理 通过各种人口统计学和临床因素，我还将使用项目 结果提出政策和方案解决方案，以减少护理和安全网中的不公平现象 设置.为了实现这些目标，我将追求以下具体目标：1）使用传统的 扎根理论方法进行n=25-30定性访谈的各种人际，社会文化， 有证和无证成人急诊就医行为的结构性影响 患者; 2）使用一个连接的，县范围内的行政，账单和索赔数据集，以确定 潜在可预防与不可预防紧急情况的人口统计学和临床特征 城市安全网艾德中有记录和无记录成年患者的科室利用率;以及 3)合并特定目标1-2中的数据集，并对如何进行全面的混合方法分析 各种临床的，人际的，社会文化的，和结构性的影响紧急护理寻求交叉， 在不同的病例对照组之间和组内存在分歧和趋同-包括入院原因 出生国和主要语言，以及保险类型和住房状况- 记录和未记录的成年患者在城市，安全网ED。结果：通过提供一个 全面了解文件状态作为艾德安全使用的社会决定因素- 该项目将帮助确定最佳的短期和长期政策和方案解决方案， 改善有文件证明和无文件证明的安全网艾德患者获得公平、高质量医疗保健的机会。

PROJECT SUMMARY/ABSTRACT BACKGROUND: As a historically minoritized and marginalized population, undocumented immigrants residing in the US face unique and intersecting social and structural inequities in health care access and outcomes. Undocumented immigrants are significantly more likely to report limited access to health insurance coverage, less use of preventive health services, and worse health outcomes as compared to their documented counterparts. Due in-part to exclusionary policies limiting access to comprehensive health insurance coverage, many undocumented immigrants are left with little to no choice but to search for alternative care seeking strategies, including use of safety net emergency departments (EDs) for potentially preventable conditions when experiencing health needs. However, undocumented immigrants remain largely underrepresented in the emergency care utilization literature. ED utilization for ambulatory sensitive care conditions (ACSCs) - conditions for which good outpatient care and early intervention can prevent complications, hospitalization, or more severe disease – are a costly form of health care that have been associated with various social determinants of health, including lack of insurance, however, documentation status as a social determinant of ED utilization for ACSCs is notably missing in the health utilization literature. METHODS: I propose an in-depth investigation of documentation status as a social determinant of ED utilization for ACSCs and non-ACSC in the safety-net setting. In addition to studying the ED care seeking behaviors of adult safety-net patients by various demographic and clinical factors, I will also use project results to propose policy and program solutions for reducing inequities in care and access in the safety-net setting. To accomplish these objectives, I will pursue the following specific aims: 1) Use a traditional grounded theory approach to conduct n=25-30 qualitative interviews on various interpersonal, sociocultural, and structural influences of emergency care seeking behaviors in documented and undocumented adult patients; 2) Use a concatenated, county-wide administrative, billings, and claims dataset to identify demographic and clinical characteristics of potentially preventable vs. non-preventable emergency department utilization among documented and undocumented adult patients at an urban safety-net ED; and 3) Merge datasets from Specific Aims 1-2 and conduct a comprehensive mixed-methods analysis of how various clinical, interpersonal, sociocultural, and structural influences of emergency care seeking intersect, diverge, and converge among and within distinct case-comparison groups – including reason for admission and disposition, country of birth and primary language, and insurance type and housing status - in documented and undocumented adult patients at an urban, safety-net ED. RESULTS: By providing a comprehensive understanding of documentation status as a social determinant of ED utilization in the safety- net setting, this project will help identify the best immediate and long-term policy and program solutions for improving access to equitable, quality healthcare for documented and undocumented safety-net ED patients.