Understanding and Addressing Disparities in Primary Care: A National Mixed Methods Study

摘要 美国国内的健康差距普遍存在，对某些人群来说，差距还在扩大。高质量的初级 护理在许多慢性健康疾病的预防、诊断和管理中发挥着重要作用。 造成老年人健康差距的条件。美国的初级保健，然而 威胁。即使在COVID-19之前，初级保健医生的人均供应量也在下降，而且变化很大 严重威胁到农村和其他不太富裕的社区。很少有人知道如何 近年来，获得高质量初级保健的机会发生了变化， COVID-19大流行-或与更好地 老年人初级保健的质量。这些理解上的差距阻碍了我们作为一个国家， 为老年人提供最好的照顾。该项目将利用一个独特的国家 数据集，包括所有美国初级保健实践的所有权和人员配备的年度信息， 2015 - 2024年，关联的医疗保险索赔数据，以及对这些做法的全国代表性样本的调查 在2017年和2022年进行。本项目的工作将包括：目标1：审查美国在获得初级教育方面的趋势 在传统的按服务收费和Medicare Advantage中照顾Medicare受益人，并确定如何 这些趋势在低收入人群中各不相同。该小组将进行重复的横断面研究， 医疗保险参保者获得初级和相关专科护理的机会，以及获得护理的趋势 不同的是，人口较少。目标2：确定政策、制度和实践层面的因素 与更好的医疗保险受益人的护理过程和结果相关，重点关注那些 较少的社会和经济利益。该团队将利用 国家，交付系统和医生的做法，在实施旨在改善和 支持初级保健应用差异中的差异方法，以确定潜在的高影响因素。 目标3：进行定性研究，加深我们对潜在障碍和促进因素的理解， 改善贫困人口的初级保健。在这一目标下，该小组将进行关键线人 与政策、初级保健和安全网方面的专家进行访谈，以加深我们对当前 安全网做法面临的挑战和机遇。然后，团队将有目的地对实践进行抽样， 参加了2022年的调查，为经济上不太富裕和少数民族人口服务， 与其领导人和工作人员进行深入的定性访谈。这三个目标的结果将是 进行三角分析，以制定可以帮助实践领导者、卫生系统领导者和 政策制定者在改善初级保健和减少老年人健康差距方面的作用。

ABSTRACT Disparities in health within the U.S. are pervasive and, for some populations, widening. High-quality primary care plays an important role in the prevention, diagnosis and management of the many chronic health conditions that contribute to health disparities among older adults. Primary care in the U.S., however, is threatened. Even before COVID-19, the per-capita supply of primary care physicians was falling and varied dramatically by county, threatening rural and other less-advantaged communities. Little is known about how access to high-quality primary care has changed in recent years—including changes in access associated with the COVID-19 pandemic—or about the policy-, system-, or practice-level factors that are associated with better quality of primary care for older adults. These gaps in understanding have hindered our ability, as a nation, to provide the best care to older adults. This project will address this need by drawing on a unique national dataset that includes annual information on the ownership and staffing of all U.S. primary care practices from 2015–2024, linked Medicare claims data, and surveys of nationally representative samples of these practices conducted in 2017 and 2022. Work in this project will entail: Aim 1: Examine U.S. trends in access to primary care for Medicare beneficiaries in traditional Fee-for-Service and Medicare Advantage and determine how these trends varied for less-advantaged populations. The team will conduct repeated cross-sectional studies of access to primary and relevant subspecialty care for Medicare enrollees and how trends in access to care varied for less-advantaged populations. Aim 2: Identify the policy-, system-, and practice-level factors associated with better processes and outcomes of care for Medicare beneficiaries, with a focus on those with fewer social and economic advantages. The team will take advantage of the substantial differences across states, delivery systems, and physician practices in the implementation of initiatives intended to improve and support primary care to apply differences-in-differences approaches to identify potentially high impact factors. Aim 3: Conduct qualitative research to deepen our understanding of the underlying barriers and facilitators to improving primary care for less advantaged populations. Under this aim, the team will conduct key informant interviews with experts on policy, primary care and the safety net to deepen our understanding of current challenges and opportunities facing safety net practices. The team will then purposively sample practices that participated in the 2022 survey that serve economically less-advantaged and minoritized populations and conduct in-depth qualitative interviews with their leaders and staff. Findings across these three aims will be triangulated to develop recommendations that can assist practice leaders, health system leaders, and policymakers in improving primary care and reducing health disparities for older adults.