Outcomes in Patients with Multimorbidity at Ambulatory Surgical Centers

摘要 门诊外科中心(ASCs)的手术量增长与 对老年人和更脆弱的多发病(MM)患者进行手术。这项提议旨在 为了检查在ASC或在医院环境中接受治疗的多病患者的结果， 包括医院门诊(HOPD)和住院设置，以便提供关于MM在哪里的指导 病人应该得到他们的照顾。理解这个问题的答案将极大地指导旨在 保护多发性骨髓瘤患者，并为患者和他们的外科医生提供指导，了解 手术环境和患者是确保更好结果的重要因素。因为这个决定 对多发性骨髓瘤患者进行手术必须权衡多发性骨髓瘤人群中增加的手术风险，而且因为 手术环境的选择(ASC与医院)对此计算至关重要，我们将提供具体的 研究这个设置问题的方法，我们的目标是通过使用 多变量匹配。目标1将定义在ASCS，医院门诊(HOPD)进行的手术模式 在患有和不患有多发性骨髓瘤的老年患者中使用新的虚拟研究数据中心 CMS，使我们能够检查从2008年到2017年的全国数据。使用我们的新方法来定义 MM用于普通外科和骨科手术，并探索眼科和诊断程序，我们 将能够描述环境方面的差异(包括ASC、医院和 医生)，适用于ASC和医院环境之间的手术患者，无论是否有MM。目标2 将通过以下方式检查MM病例的初始ASC和初始HOPD设置之间的结果差异 多变量匹配的使用。假设2.1将探索匹配的多发性骨髓瘤患者预后的差异 在ASC和HOPD设置之间。假设2.2将探索匹配的MM之间结果的差异 和非MM患者(通过特定的ASC设置来探索MM患者的不同结果 ASC的特征，使用所有权、数量、与医院相关的位置、麻醉人员配备、 医生特征，以及ASC病例组合与个别指标病例的“一致性”)。假设2.3将 在ASC和HOPD设置下，检查特定MM患者亚组之间的结果差异。目标3 我将使用假设检验非MM病例在ASC和HOPD设置中的结果差异 通过这项研究，我们的目标是确定多发性骨髓瘤患者的程序和类型，这些患者应该 鼓励或不鼓励在特定环境下进行手术以改善预期 对这一特别脆弱的人群的影响。此外，使用类似的分析方法，我们还将 了解非MM人群在不同环境中的不同结果。最后，我们的研究结果 应该直接有助于决定在哪里为患者进行手术。 医疗保险人口。

Abstract The growth in procedure volume at Ambulatory Surgical Centers (ASCs) has coincided with the growth in surgery performed on the elderly and on more vulnerable patients with multimorbidity (MM). This proposal aims to examine outcomes of patients with multimorbidity who were treated either at an ASC or at a hospital setting, including hospital outpatient (HOPD) and inpatient settings, in order to provide guidance as to where MM patients should receive their care. Understanding the answer to this question will greatly inform policy aimed at protecting patients with MM, and provide guidance to patients and their surgeons about what characteristics of the operative setting and the patient are important for ensuring better outcomes. Because the decision to operate on a patient with MM must weigh the increased operative risks in the MM population, and because the choice of operative setting (ASC versus hospital) is critical to this calculation, we will present specific approaches to studying this setting question, we aim to closely define patient characteristics through the use of multivariate matching. AIM 1 will define the pattern of surgery performed at ASCs, hospital outpatient (HOPD) and inpatient locations in elderly patients with and without MM using the new Virtual Research Data Center at CMS, allowing us to examine the entire country's data from 2008 to 2017. Using our new approach to defining MM for general surgery and orthopedic surgery, and exploring ophthalmologic and diagnostic procedures, we will be able to describe differences in setting (including by the characteristics of ASCs, hospitals, and physicians) for patients undergoing surgery, with and without MM, between ASC and hospital settings. AIM 2 will examine differences in outcomes across initial ASC and initial HOPD settings for MM cases through the use of multivariate matching. Hypothesis 2.1 will explore differences in outcomes for matched MM patients between ASC and HOPD settings. Hypothesis 2.2 will explore differences in outcomes between matched MM and non-MM patients by specified ASC settings (exploring differential outcomes in MM patients by the characteristics of the ASC, using ownership, volume, location in relation to hospitals, anesthesia staffing, physician characteristics, and "alignment" of ASC case-mix to the individual index case). Hypothesis 2.3 will examine outcome differences between specific MM patient subgroups at the ASC versus HOPD setting. AIM 3 will examine differences in outcomes across ASC and HOPD settings for the non-MM cases using hypotheses parallel to AIM 2. Through this research, we aim to identify procedures and types of MM patients that should be encouraged to or discouraged from having surgery in specific settings in order to improve expected outcomes for this especially vulnerable population. Furthermore, using a similar analytic approach, we will also learn about differential outcomes across settings in the non-MM population. In the end, our study results should be directly helpful in informing the decision regarding where to undergo surgery for patients in the Medicare population.