Expansion of Percutaneous Coronary Intervention in Outpatient and Inpatient Settings: Quantifying the Differential Impact Between Disadvantaged and Non-Disadvantaged Communities

项目摘要/摘要 门诊和住院患者经皮冠状动脉介入治疗的扩展：量化 弱势社区和非弱势社区之间的差异影响 在部署医学技术时，往往没有明确关注弱势群体 人口，有这样一种观念：“水涨船高”。然而，现在很明显，这种假设并不成立。 确实如此，特别是在心脏护理和经皮冠状动脉介入治疗(PCI)可获得性方面。种族 而少数民族、低收入个人和没有保险的人，这种情况持续甚至扩大 在获取、治疗和结果方面的不平等。不幸的是，这些文献主要集中在 个人或机构层面的歧视。我们的长期目标是在 心脏护理扩大了弱势和非弱势社区和患者之间的差距。 我们的中心假设是，目前的冠脉介入治疗增长模式对 弱势社群与非弱势社群，以及分开研究这些社群 使我们能够揭开在观察平均效果时可能看不到的差异。vbl.使用 将PCI扩展作为一种身份识别策略，以及来自加利福尼亚州的10年患者级别数据，我们 建议检验门诊和住院患者经皮冠状动脉介入治疗增长的假设：(目标1)增加 与弱势患者相比，非弱势患者接受冠状动脉介入治疗的风险更高或不合适的可能性更大 社区；(目标2)将患者分布改变为劣势而不是优势的低质量设施 社区；以及(目标3)拉大了弱势群体和非弱势群体患者之间的健康差距 患者个人资料和/或冠状动脉介入治疗设施质量的变化对弱势群体的影响。 这项研究具有创新性，因为它提出了：a)一种纵向的、基于人口的方法来研究所有 在门诊和住院环境中进行PCI，而不是仅仅依赖基于医院的PCI值或PCI值； B)采用多层次(个人、医院和社区)的方法来了解不同的经验 患者、设施和社区的技术扩展；以及c)使用结构性种族主义和 歧视镜头聚焦于建筑环境，呈现了一个可干预的目标。 我们的研究结果可以为地方、州甚至联邦政策等干预措施提供信息 改变。目前的趋势似乎是允许尽可能多的医院成为PCI- 有能力，有有效的立法(例如，加利福尼亚州AB 370，新泽西州A1176)。当前的政策和立法做到了这一点 不考虑对股权的影响，也不纳入明确的质量指标。潜在政策的示例 变化包括对法律和监管方面的改革，如许可、认证、报销、 和责任；修订PCI中心的定义要求；或符合以下条件的需要证明规定 深思熟虑地纳入针对健康差距人口的基于人口的公平措施。

Project Summary/Abstract Expansion of Percutaneous Coronary Intervention in Outpatient and Inpatient Settings: Quantifying the Differential Impact Between Disadvantaged and Non-Disadvantaged Communities Technology in medicine has often been deployed without explicit attention to disadvantaged populations, with the idea that “a rising tide lifts all boats.” Yet it is now clear that this assumption has not held true, particularly in the field of cardiac care and availability of percutaneous coronary intervention (PCI). Racial and ethnic minorities, low-income individuals, and the uninsured experience persistent and even widening inequalities in access, treatment, and outcomes. Unfortunately, the literature has focused primarily on discrimination at the individual or institutional level. Our long-term goal is to identify system-level pathways in cardiac care that widen disparities between disadvantaged and non-disadvantaged communities and patients. Our central hypothesis is that that the current pattern of PCI growth has differentially affected disadvantaged versus non-disadvantaged communities, and that studying these communities separately allows us to unmask differences that could otherwise be undetected when looking at the average effect. Using PCI expansion as an identification strategy along with 10 years of patient-level data from California, we propose to test the hypothesis that the growth of outpatient and inpatient PCI has: (Aim 1) increased the likelihood of higher-risk or inappropriate patients receiving PCI in non-disadvantaged relative to disadvantaged communities; (Aim 2) changed patient distribution to low-quality facilities in disadvantaged versus advantaged communities; and (Aim 3) widened the health disparity gap between patients in disadvantaged and non- disadvantaged communities through changes in patient profile and/or the quality of PCI facility. This study is innovative because it proposes: a) a longitudinal, population-based approach to study all PCIs done in both outpatient and inpatient settings, not relying solely on hospital-based PCI or PCI registries; b) a multi-level (individual, hospital, and community) approach to understand differential experiences of technology expansion for patients, facilities, and communities; and c) use a structural racism and discrimination lens to focus on the built environment, which present an intervenable target. Findings from our research could inform interventions such as local, state, or even federal policy changes. The current trend appears to be toward allowing as many hospitals as possible to become PCI- capable, with active legislation (e.g., California AB 370, New Jersey A1176). Current policies and legislation do not consider impact on equity nor do they incorporate explicit quality metrics. Examples of potential policy changes include reforms to legal and regulatory changes regarding licensing, credentialing, reimbursement, and liability; revising definitional requirements of a PCI center; or certificate of need regulations that thoughtfully incorporate population-based equity measures for health disparity populations.