Adapting Enhanced Recovery Programs (ERPs) through Health Literacy to Eliminate Surgical Disparities

项目摘要 理由：健康素养低影响了超过三分之一的手术人群， 手术结果更差。迫切需要采取干预措施，减少这一庞大人口中的差距。 我们的团队先前已经表明，增强恢复计划（ERP）减轻了外科手术中的种族差异。 结果，并提供一个务实的方式来解决手术的差距。然而，现有的ERP在以下方面效果不佳： 健康素养低的患者仍然经历更差的结果。这种差距是由于缺乏适应之间 目前的ERP和低健康素养患者的需求。通过K23，我们的团队评估了这些需求， 开发了一种新的多层次战略，以提高适合：使患者与VISuAl艾滋病，教练提供者， 卫生知识普及培训组织（VISACT）。现在有一个机会来提供和 使用基于理论的适应框架测试VISACT。成功的适应将改变现有的 ERPs，并扩大其对低健康素养人群的影响。目标：我们的长期 目标是通过以下措施，消除差距，改善低健康素养人群在外科手术中的结果 根据具体情况对现有企业资源规划进行调整。我们假设VIACT将提高对ERP的保真度， 健康素养低的患者，从而手术结果的组成部分。为了实现我们的目标，我们的目标是： (SA1)确定ERP的健康素养敏感成分，以增加VISACT，（SA 2）评估 提供者和ERP团队组织单位的健康素养需求，以及（SA 3）交付和试点测试 关于现有机构资源规划的VISACT实施战略。方法：以动态适应过程为指导 框架，我们将首先在大型ERP数据库（n> 7，000）上使用机器学习来识别健康素养- ERPs的敏感成分，以增加与VIACT（SA 1）。其次，我们将使用一个收敛的混合- 方法采用综合方法，确定卫生知识普及方面的差距，最佳做法， 通过三种相互关联的方法来适应ERP实施团队： 在4个亚拉巴马的设施，扩大了120个利益相关者的半结构化访谈，并调查测量健康 识字知识和组织适应准备。第三，我们将在2013年向两个地点交付VIACT。 亚拉巴马（城市和农村）通过一个新的互动反应平台，在试点研究和评估， 通过RE-AIM的覆盖范围、有效性、采用、实施和 维护措施。获得的数据将为多机构阶梯楔形试验的设计提供信息， 深入南方的视野。意义：这项研究将推进NIH/NIMHD的使命，以消除外科手术 差异，并直接响应NIMHD科学愿景研究战略， 扫盲障碍（#24）和建立适应不同情况的干预措施的科学（#30）。我们的团队将 此外，（i）在外科手术中提供第一个健康知识干预，（ii）建立一个新的实施战略 （VISACT），以解决手术的差异和（iii）通过调整推进干预科学。

PROJECT SUMMARY Rationale: Low health literacy affects over a third of surgical populations and is associated with significantly worse outcomes in surgery. Interventions that reduce disparities in this large population are urgently needed. Our team has previously shown that enhanced recovery programs (ERPs) mitigate racial disparities in surgical outcomes and offer a pragmatic way to address surgical disparities. Existing ERPs, however, work poorly for patients with low health literacy who still experience worse outcomes. This gap arises from the lack of fit between current ERPs and the needs of low health literacy patients. Through a K23, our team assessed these needs and developed a novel multilevel strategy to improve fit: engage patients with VISuAl aids, Coach providers in communication, and Train organizations in health literacy (VISACT). An opportunity now exists to deliver and test the VISACT using a theory-based adaptation framework. Successful adaptations would transform existing ERPs and broaden its disparity-reducing impact to low health literacy populations. Objectives: Our long-term objective is to eliminate disparities and improve outcomes for low health literacy populations in surgery through context-driven adaptations of existing ERPs. We hypothesize that VISACT will improve fidelity to ERP’s components for low health literacy patients and thereby surgical outcomes. To achieve our objective, we aim to: (SA1) identify the health literacy-sensitive components of ERPs to augment with VISACT, (SA2) assess the health literacy needs of providers and organizational units on ERP teams, and (SA3) deliver and pilot test the VISACT implementation strategy on existing ERPs. Methods: Guided by the Dynamics Adaptation Process framework, we will first use machine learning on a large ERP database (n>7,000) to identify the health literacy- sensitive components of ERPs to augment with VISACT (SA1). Second, we will use a convergent mixed- methods integrative approach to identify gaps in health literacy knowledge, best practices, and preparedness to adapt on ERP implementation teams through three interrelated methods: in vivo observations of ERPs in-action at 4 Alabama facilities, extended semi-structured interviews of 120 stakeholders, and surveys measuring health literacy knowledge and organizational preparedness to adapt. Third, we will deliver the VISACT to two sites in Alabama (urban and rural) through a novel interactive response platform in a pilot study and assess for feasibility/acceptability through a RE-AIM framework of reach, efficacy, adoption, implementation, and maintenance measures. Acquired data will inform design of a multi-institutional stepped-wedge trial of the VISACT in the Deep South. Significance: This study will advance the NIH/NIMHD mission to eliminate surgical disparities and responds directly to the NIMHD Science Visioning Research Strategies by removing health literacy barriers (#24) and building the science of adapting interventions to different contexts (#30). Our team will furthermore (i) deliver the first health literate intervention in surgery, (ii) establish a novel implementation strategy (VISACT) to address surgical disparities and (iii) advance the science of interventions through adaptations.