Use of Inter-Hospital Transfer Services in Critical Illness and Acute Respiratory Failure

项目摘要/摘要 这一K08奖项将确立Christopher Worsham，医学博士，公共卫生硕士作为临床医生-研究人员的健康 服务研究人员使用高级因果方法检查危重护理服务及其价值 推论。沃沙姆博士是哈佛大学的医学讲师、肺病专家和重症监护内科医生 医学院和马萨诸塞州总医院。在他的临床训练的基础上，先前的研究 经验，以及在定量方法方面的课程工作，这个奖项将使他在(1)方面发展专业知识 使用大型管理数据集进行因果推断的高级方法，(2)医院间危重护理 运输服务，重点是急性呼吸衰竭(ARF)，以及(3)决策科学和成本- 有效性分析。为了实现这些目标，沃沙姆博士组建了一个拥有以下领域专长的团队：健康 服务研究和因果推理的高级方法(Anupam Jena博士、Mary Beth Landrum博士、 Hannah Wunsch和Bruce Landon)；重症护理医学和ARF(泰勒·汤普森医生)；重症护理 ARF中的运输(Susan Wilcox博士)；决策科学和成本效益分析(Ankur Pandya博士)。 危重病患者的医院间转运是美国危重病护理系统的常见做法， 通常是为了将病人转移到重症监护病房(ICU)资源与 他们的急性疾病的严重性。然而，我们并不完全了解目前各国在国际贸易中的做法模式。 跨不同患者群体的医院ICU转移。我们也缺乏对临床益处的可靠估计或 使用特别昂贵的空中救护车服务在医院之间快速运送ICU患者的价值， 包括那些患有ARF的患者，这是ICU入院的最常见原因。 为了解决重症监护系统中的这些重要问题，沃沙姆博士将分析来自 两个大型保险索赔数据库，Medicare和MarketScan商业保险索赔数据库。 在目标1中，他将描述与医院间ICU转移相关的当前做法和风险因素 成人重症监护室的总人数。在目标2中，专注于ARF患者，他将评估空气的影响 与使用新的工具变量方法的地面医院间运输相比， 无法测量的混乱，利用随机天气条件推动患者出行 地面而不是空中。在目标3中，他将使用决策科学的方法来执行成本效益 分析比较空中与地面医院间运送ARF患者的情况，以告知高价值护理。这 工作和培训将为他未来的R01提案提供基础，该提案审查常见的和昂贵的 使用先进的方法在美国重症监护系统中影响患者的做法 因果推断和成本-效果分析。这款K08和未来的R01将为床边决策提供信息 以及围绕美国重症监护系统中的资源分配和高价值护理的政策。

PROJECT SUMMARY/ABSTRACT This K08 award will establish Christopher Worsham, MD, MPH as a clinician-investigator health services researcher examining critical care services and their value using advanced methods of causal inference. Dr. Worsham is an Instructor in Medicine, pulmonologist, and critical care physician at Harvard Medical School and Massachusetts General Hospital. Building on his clinical training, prior research experience, and coursework in quantitative methods, this award will allow him to develop expertise in (1) advanced methods of causal inference using large administrative datasets, (2) inter-hospital critical care transport services with an emphasis on acute respiratory failure (ARF), and (3) decision science and cost- effectiveness analysis. To achieve these goals, Dr. Worsham has assembled a team with expertise in: health services research and advanced methods of causal inference (Drs. Anupam Jena, Mary Beth Landrum, Hannah Wunsch, and Bruce Landon); critical care medicine and ARF (Dr. Taylor Thompson); critical care transport in ARF (Dr. Susan Wilcox); and decision science and cost-effectiveness analysis (Dr. Ankur Pandya). The inter-hospital transfer of critically ill patients is a common practice in the U.S. critical care system, generally done to move patients to hospitals with intensive care unit (ICU) resources commensurate with the severity of their acute illness. However, we do not fully understand current national practice patterns of inter- hospital ICU transfer across diverse patient populations. We also lack robust estimates of clinical benefits or value of using particularly costly air ambulance services to rapidly move ICU patients between hospitals, including those with ARF, the most common reason for ICU admission. To address these important questions in the critical care system, Dr. Worsham will analyze data from two large insurance claims databases, Medicare and the MarketScan commercial insurance claims database. In Aim 1, he will characterize current practices and risk factors associated with inter-hospital ICU transfer in the overall adult ICU population. In Aim 2, focusing on patients with ARF, he will estimate the effect of air compared to ground inter-hospital transport using a novel instrumental variables approach that accounts for unmeasured confounding by taking advantage of the random weather conditions that push patients to travel by ground rather than air. In Aim 3, he will use methods of decision science to perform a cost-effectiveness analysis of air compared to ground inter-hospital transport of patients with ARF to inform high-value care. This work and training will provide him the basis for a future R01 proposal that examines common and costly practices that impact patients as they move through the U.S. critical care system using advanced methods of causal inference and cost-effectiveness analysis. This K08 and future R01 will inform bedside decision making and policy surrounding resource allocation and high-value care in the U.S. critical care system.