Understanding Regional Critical Care Delivery in Acute Respiratory Failure

 描述(由申请人提供)：需要机械通气的急性呼吸衰竭是医疗系统的巨大临床和经济负担，每年在美国影响超过75万名患者。这些患者的发病率和死亡率很高，特别是在年病例量较低的小医院。为了改善这些患者的预后，许多专家建议采用类似于美国创伤系统的区域化机械通气方法。在区域化的情况下，住进资源匮乏的小型医院的机械通风患者将被系统地分流到大型区域转诊医院。区域化有可能挽救生命，增加需要机械通风的患者获得高质量危重护理的机会。然而，实施工作面临重大障碍，最明显的是缺乏经验数据表明，将护理集中在区域优秀医院实际上可以改善结果。尽管许多研究表明，与低流量医院相比，高流量医院的机械通风效果更好，但这些研究未能完全揭示区域化护理的影响，这不仅涉及增加某些医院的病例量，还涉及减少其他医院的病例量。在取得进展之前，临床医生和政策制定者需要关于在现实世界环境中地区化危重护理的影响的经验数据。本项目的总体目标是对急性呼吸衰竭患者进行区域化危重护理的结果效益进行经验性评估。在目标1中，我们将定义新的重症护理转诊区域，作为量化区域护理提供的地理基础。在目标2中，我们将确定与更集中的急性呼吸衰竭护理相关的区域因素。在目标3中，我们将确定集中危重护理与急性呼吸衰竭患者预后之间的关系。完成这些目标将提高我们对急性呼吸衰竭的区域化和预后之间的关系的了解，并为未来集中治疗其他高危患者的努力提供科学基础。该研究计划将通过该领域专家的密集指导和匹兹堡大学和卡内基梅隆大学的教学研究培训来补充。总之，本文描述的研究项目、指导和课程工作将在以下领域为主要研究人员提供基本的职业发展：(1)空间流行病学和卫生保健地理信息系统分析，(2)高级分层统计建模和(3)组织科学和卫生保健市场分析。最终，这项工作将为评估其他时间敏感疾病的集中护理的研究奠定基础 全面的R01资助项目，并独特地将主要研究人员定位为使用地理建模来改善危重患者预后的未来领导者。

 DESCRIPTION (provided by applicant): Acute respiratory failure requiring mechanical ventilation is an enormous clinical and financial burden on the health system, affecting over 750,000 patients in the United States each year. These patients experience substantial morbidity and mortality, particularly in small hospitals with low annual caseloads. To improve outcomes for these patients, many experts propose a regionalized approach to mechanical ventilation, analogous to the United States trauma system. Under regionalization, mechanically ventilated patients admitted to small, resource-poor hospitals would be systematically triaged to large regional referral hospitals. Regionalization has potential to save lives and increase access to high-quality critical care for patients requiring mechanical ventilation. Yet, implementation efforts face significant barriers, most notably the lack of empirical data demonstrating that centralizing care in regional hospitals of excellence actually improves outcomes. Although many studies demonstrate that mechanical ventilation outcomes are better at high-volume hospitals compared to low-volume hospitals, these studies fail to fully uncover the implications of regionalized care, which involves not only increasing case volume at some hospitals but also decreasing it at others. Prior to moving forward, clinicians and policy makers require empirical data on the implications of regionalized critical care in real-world settings. The overall goal of this project is to empirically evaluate the outcome benefit of regionalized critical care for patiets with acute respiratory failure. In Aim 1 we will define novel critical care referral regions as a geographic foundation for quantifying regional care delivery. In Aim 2 we will identify regional factors associated with greater centralization of care for acute respiratory failure. In Aim 3 we will determine the association between centralized critical care and outcomes for patients with acute respiratory failure. Completion of these Aims will both advance our knowledge of the relationship between regionalization and outcomes for acute respiratory failure, as well as provide a scientific foundation for future efforts to centralize care for other high-risk patients.The research plan will be augmented by intensive mentoring by experts in the field and didactic research training at the University of Pittsburgh and Carnegie Mellon University. Together, the research project, mentoring and coursework described herein will provide the primary investigator with essential career development in the areas of: (1) spatial epidemiology and health care geographical information systems analysis, (2) advanced hierarchical statistical modeling and (3) organizational science and health care market analysis. Ultimately, this work will set the stage for research evaluating centralized care of other time-sensitive conditions in a comprehensive R01-funded project and uniquely position the primary investigator as a future leader in the use of geographic modeling to improve outcomes for critically ill patients.