ASSESSING THE VARIABILITY IN TIME TO TREATMENT IN SURGER

许多因素影响患者寻求医疗护理的决定， 他们会出现疾病的症状。 不同的因素影响 患者一旦决定进入医疗保健系统， 他们希望。 然而，一组不同的考虑因素影响了 提供及时有效的护理。对于一些外科手术 在这种情况下，提供最终护理的延误特别有可能 增加严重不良后果的频率，包括死亡， 即时并发症和长期残疾。 对于这些延迟敏感的条件，我们目前非常了解 关于治疗时间和结果之间的关系， 总时间的哪些部分是最重要的决定因素 以及哪些组成部分可以修改。 过去的工作有 专注于心肌梗死和创伤等疾病， 强调的特定时间段（例如，从受伤到 医院;从胸痛发作到急诊室门口的时间）。 没有一 阐述了一个概念框架， 可能影响延迟的因素。 其中包括患者因素 （知识、信念和应对策略），医生因素 （知识，诊断敏锐度），医院因素（可用性 诊断测试和手术室），以及卫生系统因素（健康 保险、使用管理、守门）。 我们建议研究三种延迟敏感的情况：阑尾炎， 宫外孕和肠梗阻 在第一阶段，我们将 回顾性地审查医疗记录以确定 治疗总时间和健康结果之间的关系， 在不同的时间段，不同的成分。 多变量分析 将允许我们检查治疗时间的影响， 根据年龄和合并症进行调整。 在第二阶段，我们将收集 数据同时来自患者和他们的医生，以及来自 医疗记录，以评估患者，医生和 导致治疗时间变化的卫生系统因素。 这些分析将大大提高我们对 治疗时间与健康结果之间的关系。研究 三个条件将允许一些初步观察， 这些关系是在不同的临床环境中。 这些数据也可能导致关于哪些因素与 延迟可能是可以修改的，导致具体的设计 采取干预措施，减少延误，改善成果。

Many factors influence patients' decisions to seek medical care when they experience symptoms of illness. Different factors influence the ability of patients to enter the health care system once they decide they wish to. Yet a different set of considerations affect the provision of timely and effective care. For a number of surgical conditions, delays in providing definitive care are especially likely to increase the frequency of serious adverse outcomes, including death, immediate complications, and long-term disability. For these delay-sensitive conditions, we currently understand very little about the relationship between time to treatment and outcomes, which components of this total time are the most important determinants of outcome, and which components may be modifiable. Past work has focused on conditions such as myocardial infarction and trauma and has emphasized particular segments of time (e.g., time from injury to hospital; time from onset of chest pain to emergency room door). None has articulated a conceptual framework that encompasses the full range of factors that might influence delays. These include patient factors (knowledge, beliefs, and coping strategies), physician factors (knowledge, diagnostic acumen), hospital factors (availability of diagnostic tests and operating rooms), and health system factors (health insurance, utilization management, gatekeeping). We propose to study three delay-sensitive conditions: appendicitis, ectopic pregnancy, and intestinal obstruction. In phase 1, we will review medical records retrospectively to establish the relationship between overall time to treatment and health outcomes and to examine variability in different components of this time. Multivariate analysis will permit us to examine the effect of time to treatment after adjustment for age and comorbid conditions. In phase 2, we will gather data concurrently from patients and their physicians, as well as from medical records, to assess the full range of patient, physician, and health system factors contributing to variability in time to treatment. These analyses will substantially improve our understanding of the relationship between time to treatment and health outcomes. Studying three conditions will permit some initial observations about how unique or generalizable these relationships are in different clinical settings. These data may also lead to hypotheses about which factors associated with delays might be modifiable, leading to the design of specific interventions to reduce delays and improve outcomes.