The Value of Emergency Care For Injured Older Adults

 描述(由申请人提供)：我们将以之前收集的获得7个县911急救医疗服务(EMS)的受伤老年人的预期队列为基础，通过匹配伤害前/伤害后医疗保险数据、州创伤登记、州出院数据和临终偏好。然后，我们将使用长期结果、资源使用和成本来评估紧急护理对受伤老年患者的价值。重要性：目前的EMS分诊做法无法识别许多患有严重伤害的老年人，导致将其送往非创伤医院(分诊不足)，并可能导致更糟糕的结果。分诊不足被过度分诊(将轻伤患者运送到主要创伤中心)所抵消，这会导致不必要的成本、护理中断和无法衡量的好处。然而，几乎没有研究来描述和理解这些问题，特别是在老年人中。这个项目 将严格解决老年人特有的EMS分诊做法，包括合并症、药物使用、临终偏好、功能性生存、资源使用和成本的作用。我们还将验证新的分诊指南，以更好地识别严重受伤的老年人，并与目前的分诊做法进行比较。该项目将填补关键的科学空白，并为下一次修订国家EMS分类指南提供信息。目的：该提案有3个具体目标：具体目标1.描述目前受伤老年人的急救系统，包括院外分流程序、选择医院的原因、短期和长期结果、资源使用和成本。具体目标2.改进和验证以前派生的院外风险分层工具，以更好地识别可以纳入国家分诊指南的严重受伤的老年人。具体目标3.评估目标2中的分类指南与当前分类指南相比的总体方案影响(益处、危害和成本)。研究设计：这将是对7个县、基于人群的前瞻性EMS队列的二次分析，与受伤前和受伤后的医疗保险数据、两个州创伤登记、两个州出院数据库和俄勒冈州生命维持治疗医生订单(POLST)登记相匹配。环境：包括俄勒冈州和华盛顿州的7个县(城市、郊区和农村地区)，44个急救机构和44家急救医院(4个主要创伤中心和40家非三级医院)。参与者：这项研究将包括17,909名受伤的成年人=65岁，由EMS在2011年1月1日至2011年12月31日期间运送到44家医院，代表现场分流指南适用的老年人的分母。具有严重损伤(损伤严重程度评分=16)的患者将被定义为高危患者。结果 措施：结果将包括一年的功能性生存，资源使用(重复EMS运输，重复急诊室就诊和再次入院)，以及受伤后长达一年的医疗费用。

 DESCRIPTION (provided by applicant): We will build on a previously collected prospective cohort of injured older adults accessing 911 emergency medical services (EMS) in 7 counties by matching to pre-/post-injury Medicare data, state trauma registries, state discharge data and end-of-life preferences. We will then evaluate the value of emergency care for injured older patients using long-term outcomes, resource use and costs. Importance: Current EMS triage practices fail to identify many older adults with serious injuries, resulting in transport to non-trauma hospitals (under-triage) and potentially worse outcomes. Under-triage is counter- balanced by over-triage (transport of patients with minor injuries to major trauma centers), which results in unnecessary costs, disruptions in care and no measureable benefit. However, there is little research to describe and understand these issues, particularly in older adults. This project will rigorously address EMS triage practices unique to older adults, including the role of comorbidities, medication use, end-of-life preferences, functional survival, resource use and costs. We will also validate new triage guidelines to better identify seriously injured older adult and compare to current triage practices. This project will fill key scientific gaps and inform the next revision of national EMS triage guidelines. Objectives: The proposal has 3 specific aims: Specific Aim 1. Describe the current emergency care system for injured older adults, including out-of-hospital triage processes, reasons for selecting hospitals, short- and long-term outcomes, resource use, and costs. Specific Aim 2. Refine and validate a previously derived out-of-hospital risk stratification tool to better identify seriously injured older adults that could be incorporatd into national triage guidelines. Specific Aim 3. Estimate the overall programmatic impact (benefits, harms and costs) of triage guidelines from Aim 2, compared to current triage guidelines. Study Design: This will be a secondary analysis of a 7-county, population-based, prospective EMS cohort, matched to pre- and post-injury Medicare data, two state trauma registries, two state discharge databases and the Oregon Physician Orders for Life-Sustaining Treatment (POLST) registry. Setting: The setting includes 7 counties in Oregon and Washington (urban, suburban and rural regions), 44 EMS agencies and 44 acute care hospitals (4 major trauma centers and 40 non-tertiary hospitals). Participants: The study will include 17,909 injured adults = 65 years transported by EMS to 44 hospitals between 1/1/2011 - 12/31/2011, representing the denominator of older adults to whom the field triage guidelines are applied. Patients with serious injuries (Injury Severity Score = 16) will define high-risk patients. Outcome measures: Outcomes will include 1-year functional survival, resource use (repeat EMS transports, repeat ED visits and re-admissions), and health care costs up to 1-year post-injury.