Evaluating Control of Hypertension - Effect of Social Determinants (ECHOES)

项目摘要 高血压（HTN）是美国（US）成人中最常见的慢性疾病。没有保险 成年人更有可能患有未确诊的HTN，不太可能接受定期筛查， 比投保的成年人更能控制他们的HTN。个别州医疗补助扩张的先前研究 表明获得保险增加了医疗服务的利用率， 护理和改善健康结果;但这些研究因没有对照组而受到限制。更 最近，多个州受到联邦政策变化的影响（例如，《平价医疗法案》（Affordable Care Act）， 评估获得（或失去）健康保险是否以及如何改善HTN预防的“自然实验” 和关怀.此外，各州选择扩大或缩小覆盖范围的方式存在差异， 确定“干预”和“控制”状态的机会（例如，一些州扩大了医疗补助资格， 其他人没有）。我们准备好研究ACA医疗补助扩张自然政策实验和其他 未来几年可能出现的政策变化。此外，通过健康保险获得护理可能 不足以减少高血压病护理的障碍。因此，健康的其他社会决定因素（[SDOH];例如， 个人和社区层面的因素）可能会不同程度地影响获得保险 接受HTN护理。我们将使用ADVANCE临床数据中的电子健康记录（EHR）数据 研究网络，与社区一级的SDOH相连，该网络拥有来自599个社区卫生中心的数据 （CHC），包括14个医疗补助扩展州的376个CHC（n= 1，139，779例患者）和8个非医疗补助州的224个CHC。 扩张状态（n= 658，306例患者）。从这个数据集，我们将收集有关变化的详细信息， HTN的发病率，筛查，治疗和管理，比较扩大医疗补助的州， 那不是。具体目标如下：目标1。比较HTN的发病率，未确诊的患病率 HTN和HTN筛查率，在医疗补助扩展与非扩展状态之前和之后， ACA。目标2.比较医疗补助扩张与非扩张状态下的HTN治疗和管理， 在ACA之前和之后目标3.评估HTN发病率、筛查和治疗 获得保险的患者与持续保险或未保险的患者之间的有效性， ACA，是由个人水平的SDOH（例如，种族、民族）。目标4。探索以下因素之间的相互作用 社区级SDOH（例如，邻里种族隔离和剥夺）和HTN筛查，治疗， 和管理的病人谁获得保险相对于那些谁已经投保或 没有保险，在扩张的国家我们将直接建立在我们的初步工作，并利用各种 我们的多学科团队的优势。ADVANCE数据集使我们能够独特地评估当前和 未来的自然实验调查结果将与旨在减轻 对弱势群体的高血压和营养保健方面的差距。

Project Summary Hypertension (HTN) is the most common chronic condition among adults in the United States (US). Uninsured adults are more likely to have undiagnosed HTN, less likely to receive regular screening, and less likely to have their HTN under control than insured adults. Prior studies of individual states' Medicaid expansion showed that gaining insurance increased healthcare service utilization, receipt of recommended preventive care, and improved health outcomes; but these studies were limited by having no comparison group. More recently, multiple states were impacted by federal policy changes (e.g., Affordable Care Act [ACA]), creating `natural experiments' to assess whether and how gaining (or losing) health insurance improves HTN prevention and care. Further, there is variability in how states choose to expand or contract coverage, which creates opportunities to identify `intervention' and `control' states (e.g., some states expanded Medicaid eligibility, while others did not). We are well-poised to study the ACA Medicaid expansion natural policy experiment and other policy changes that may unfold in the next few years. In addition, access to care through health insurance may be insufficient to reduce barriers to HTN care. Thus, other social determinants of health ([SDOH]; e.g., individual- and community-level factors) may differentially affect the relationship between gaining insurance and receiving HTN care. We will use electronic health record (EHR) data from the ADVANCE clinical data research network, linked to community-level SDOH, which has data from 599 community health centers (CHCs), including 376 CHCs in 14 Medicaid expansion states (n=1,139,779 patients) and 224 CHCs in 8 non- expansion states (n=658,306 patients). From this dataset, we will collect detailed information on changes in HTN incidence, screening, treatment, and management comparing states that expanded Medicaid, and those that did not. The specific aims are as follows: Aim 1. Compare HTN incidence, prevalence of undiagnosed HTN, and rates of HTN screening, in Medicaid expansion versus non-expansion states before and after the ACA. Aim 2. Compare HTN treatment and management in Medicaid expansion versus non-expansion states, before and after the ACA. Aim 3. Assess the extent to which rates of HTN incidence, screening, and treatment effectiveness among patients who gained insurance versus those continuously insured or uninsured, pre-post ACA, are moderated by individual-level SDOH (e.g., race, ethnicity). Aim 4. Explore the interaction between community-level SDOH (e.g., neighborhood racial segregation and deprivation) and HTN screening, treatment, and management among patients who gained insurance relative to those who were already insured or uninsured, in expansion states. We will build directly on our preliminary work and take advantage of the diverse strengths of our multidisciplinary team. The ADVANCE dataset uniquely positions us to assess current and future natural experiments. Findings will be relevant to policy and practice changes aimed at mitigating disparities in HTN care for vulnerable populations.