The Value of Emergency Care For Injured Older Adults

 描述（由申请人提供）：我们将建立在先前收集的受伤老年人的前瞻性队列访问911紧急医疗服务（EMS）在7个县通过匹配受伤前/受伤后的医疗保险数据，状态创伤登记，状态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受伤老年患者的紧急护理价值。重要性：目前的EMS分诊实践未能识别出许多严重受伤的老年人，导致被送往非创伤医院（分诊不足），并可能导致更糟糕的结果。分流不足与过度分流（将轻伤患者运送到主要创伤中心）相抵消，这导致不必要的成本，护理中断和没有可衡量的好处。然而，很少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EMS分流的做法，独特的老年人，包括共病的作用，药物使用，临终偏好，功能生存，资源使用和成本。我们还将验证新的分流指南，以更好地识别严重受伤的老年人，并与目前的分流做法进行比较。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。目标：该提案有三个具体目标：具体目标1。描述当前受伤老年人的紧急护理系统，包括院外分诊流程、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。完善和验证先前导出的院外风险分层工具，以更好地识别严重受伤的老年人，这些老年人可以纳入国家分诊指南。具体目标3。与当前的分诊指南相比，估计目标2中的分诊指南的总体方案影响（收益、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、两个州创伤登记处、两个州出院数据库和俄勒冈州医生维持生命治疗订单（POLST）登记处相匹配。设定：该环境包括俄勒冈州和华盛顿的7个县（城市、郊区和农村地区）、44个EMS机构和44家急性护理医院（4家主要创伤中心和40家非三级医院）。参会人员：本研究将纳入2011年1月1日至2011年12月31日期间由EMS运送至44家医院的17，909名年龄≥ 65岁的受伤成人，代表适用现场分诊指南的老年人的分母。严重损伤患者（损伤严重度评分= 16）将定义为高风险患者。结果 措施：结局将包括1年功能存活率、资源使用（重复EMS转运、重复艾德访视和再次入院）和受伤后1年的医疗保健费用。

 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.