Neighborhood transportation vulnerability and geographic patterns of diabetes-related limb loss

交通对于获得医疗保健至关重要，少数群体面临不成比例的 美国的交通障碍（US）。医疗保险覆盖范围的扩大一直是焦点， 在美国实现公平的医疗保健，但保险本身并不能保证获得医疗保健，除非 患者和供应商可以互动。美国60%的成年人患有≥1种慢性疾病， 慢性病护理模式需要患者和医疗保健之间频繁和持续的接触 系统.尽管出现了远程医疗，但大多数患者与提供者的互动都需要将患者运送到 医疗设施。美国国家一级的调查估计， 2017年由于交通障碍和有色人种面临更大的交通障碍，需要照顾。我们的目标是 调查“交通脆弱性”和慢性疾病结果之间的关系， 邻里水平，并衡量种族/民族，性别和年龄如何改变这些程度 使用糖尿病足溃疡（DFU）作为慢性疾病模型的相关性。“运输脆弱性”可以 由于一个地区缺乏交通资源，以及这些资源之间的联系不良， 资源和医疗保健地点。基于人口的研究将交通脆弱性与健康联系起来 缺乏成果。我们选择DFU作为模型，因为它们是一种破坏性的糖尿病并发症 在美国每年进行的100，000例糖尿病相关下肢截肢中，低- 低收入群体和少数种族群体承受着更大的DFU和截肢负担。重要的是 从溃疡到截肢的进展是可以预防的，充分的门诊护理和DFU有明确的 以肢体丧失形式的不良结局定义。在可行性研究的支持下，我们将开始填补这一空缺， 在这项探索性研究中，通过估计运输脆弱性与 使用2016-2020年格鲁吉亚全州医院账单数据库的DFU结局（目标1）和详细的患者- 2016-2021年两个设在埃塞俄比亚的大型卫生系统的水平记录（目标2）。这提供了一个独特的机会， 评估我们从这两个具有不同优势的数据来源中得出的结果的稳健性。我们的研究团队 具有DFU临床专业知识，以及慢性病流行病学，地理信息系统， 空间流行病学这项研究是符合NIMHD研究模型，通过检查交叉的 根据健康结果建立环境和卫生保健系统。一旦到位，所制定的框架将 扩展到调查运输脆弱性和主要糖尿病并发症之间的关系 （心肌梗死、卒中、终末期肾病和高血糖危象以及截肢） 一个国家级的。我们的长期目标是制定一个社区级的美国交通脆弱性地图， 为地方干预提供信息（例如，非紧急医疗运输服务的分配）和区域 策略（例如，发展和改善公共交通），以缩小获得保健服务方面的差距。

Transportation is paramount to health care access and minority populations face disproportionate transportation barriers in the United States (US). Health insurance coverage expansion has been the focus to achieve equitable health care in the US, but insurance alone does not guarantee access to care unless patients and providers can interact. Sixty percent of adults in the US have ≥1 chronic disease and current models of chronic disease care require frequent and ongoing contacts between patients and healthcare systems. Despite the advent of telehealth, most patient-provider interactions require patient transportation to a healthcare facility. US national-level surveys estimate 5.8 million people missed a health care appointment in 2017 due to transportation barriers and people of color face bigger transportation barriers to care. Our goal is to investigate the associations between “transportation vulnerability” and chronic disease outcomes at the neighborhood-level and to measure how race/ethnicity, sex, and age modify the magnitude of these associations using diabetic foot ulcers (DFUs) as a chronic disease model. “Transportation vulnerability” can arise from a combination of lacking transportation resources in an area, and from poor linkage between these resources and healthcare locations. Population-based studies linking transportation vulnerability to health outcomes are lacking. We choose DFU as model because they are a devastating diabetes complication preceding most of the 100,000 diabetes-related lower extremity amputations performed yearly in US. Low- income and racial minority groups experience higher burdens of DFUs and amputations. Importantly, the progression from ulceration to amputation is preventable with adequate outpatient care and DFUs have a clear poor outcome definition in the form of limb loss. Supported by a feasibility study, we will begin to fill this knowledge gap in this exploratory study by estimating the associations between transportation vulnerability and DFU outcomes using Georgia state-wide hospital billing databases, 2016-2020 (aim 1) and detailed patient- level records of two Atlanta-based large health systems, 2016-2021 (aim 2). This offers a unique opportunity to assess robustness of our findings from these two data sources with different advantages. Our research team has clinical expertise in DFUs, as well as chronic disease epidemiology, geographic information systems, and spatial epidemiology. This study is in line with the NIMHD research model by examining the intersection of the built environment and health care systems on health outcomes. Once in place, the framework developed will be extended to investigate the associations of transportation vulnerability and major diabetes complications (myocardial infarction, stroke, end-stage renal disease, and hyperglycemic crisis in addition to amputations) at a national-level. Our long-term goal is to develop a neighborhood-level US transportation vulnerability map to inform local interventions (e.g., allocation of non-emergency medical transportation services) and regional policies (e.g., development and improvement of public transit) to close disparities in healthcare access.