Effect of Bypass Policies on Stroke Treatment in a National Sample of Medicare Beneficiaries

项目摘要 对于有中风症状的人，以医院为基础的静脉注射阿尔替普酶的快速治疗对 卓越的患者预后。为了快速静脉注射阿替普酶，几个县实施了分流术 这项政策要求医护人员绕过当地急诊科，将病人直接送到 中风中心。然而，科学证据表明，这项政策带来了有效、更高质量和公平的结果 对中风患者的护理是有限的。我们建议的研究将测试政策对静脉注射阿尔替普酶的影响，30- 日间死亡率和短期和长期功能独立性..如果观察到更高的收益，该政策可能会 推广到非政策性县。在我们的前期工作(由AHRQ K08 HS17965资助)中，我们使用了 前后设计两个县，检验该政策对治疗的效果。虽然我们的工作显示出更高的 其中一个县的治疗评估仅限于两个城市县，并未对世俗进行控制 趋势。拟议的研究将通过以下三个目标解决上述限制。首先，我们将 检查旁路政策是否导致全县静脉注射阿尔替普酶使用率、死亡率和短程 长期的功能独立。对于这一分析，我们将利用发生的自然实验 在美国，这些县在八年期间(2006-2013年)在不同的时间实施了这项政策。 我们将识别896个符合该政策的县，并将其与1792个未实施绕过政策的县进行匹配(总计n =2688)，并使用差异方法来检查政策的有效性。第二，我们 将审查县级因素(例如，政策组成部分的差异、城市/郊区/农村县)是否 与对结果的不同影响有关。第三，我们将使用多案例研究设计，定性的 使用访谈对24个县(72个提供商访谈)进行深入评估的方法，县 对县卒中议定书进行调查和文件分析，以解释政策效果并确定 政策效果的推动者。我们将使用解释性顺序设计、混合方法来 将目标1和目标2中的定量数据的呼吸与目标3中的定性数据相结合，并使用联合 显示以显示调查结果。这项研究具有重要意义，因为它将提供对 政策对患者结局的影响。这项研究也符合AHRQ研究医疗保健模型的使命。 比较有效性方法，使用大型数据库进行定量评估，特别强调分 人口，如城乡差异和定性检查，目的是确定最好的 各县的惯例。

Project Summary For a person with stroke symptoms, rapid hospital-based treatment with intravenous alteplase is critical for superior patient outcomes. To rapidly deliver intravenous alteplase, several counties implemented a bypass policy that requires paramedics to bypass the local emergency departments and directly route patients to stroke centers. However, scientific evidence that the policy results in effective, higher quality and equitable care to stroke patients is limited. Our proposed study will test policy's effect on intravenous alteplase use, 30- day mortality and short- and long-term functional independence.. If higher benefit is observed, the policy could be extended to non-policy counties. In our preliminary work (funded by AHRQ K08 HS17965), we used a before-after design of two counties to test the policy's effect on treatment. Although our work showed higher treatment in one of the counties the evaluation was limited to two urban counties and did not control for secular trends. The proposed study will address the above limitations using the following three aims. First, we will examine if the bypass policy leads to increase in countywide intravenous alteplase use, mortality and short-and long term functional independence. For this analysis, we will leverage on the natural experiment that happened in the US in which counties implemented the policy at different times during an eight-year period (2006-2013). We will identify 896 counties with the policy and match them 1792 counties without the bypass policy (total n =2688) and use a difference-in-differences approach to examine the effectiveness of the policy. Second, we will examine if county factors (e.g., variation in policy components, urban/suburban/rural counties) are associated with differential effects on outcomes. Third, we will use a multiple case study design, a qualitative approach to perform in-depth evaluation of 24 counties (72 provider interviews) using interviews, county surveys and document analysis of the county stroke protocols, to explain the policy effect and identify the enablers of the policy's effect. We will use an explanatory sequential design, a mixed-methods approach, to integrate the breath of the quantitative data in aims 1 and 2 with the qualitative data in aim 3 and use a joint display to present the findings. This study is significant because it will provide an accurate estimate of the policy effect on patient outcomes. The study also fits with AHRQ' mission on study of healthcare models using comparative effectiveness methods, quantitative evaluation using large databases, special emphasis on sub- population such as urban-rural differences and a qualitative examination with the goal of identifying best practices for the counties.