Causes and Consequences of Healthcare Inequity in Alzheimer's Disease and Related Dementias

摘要 由于支出飙升和预期寿命停滞不前，该计划项目赠款的前20年 (PPG)一直专注于美国医疗保健效率的原因和后果。 先进的基础科学知识，关于低效率的来源，并激励了显着 医疗保健政策的变化和数百万美国人的交付。这种竞争性的更新是对 NIA优先考虑阿尔茨海默病和相关痴呆症（ADRD）相关研究， 通过将这一PPG的重点转移到卫生保健服务和为人们提供服务方面的不平等， 用反种族歧视和种族不平等的透镜。这是一个新的框架，从工作到目前为止， 这个PPG。不平等是医疗保健效率低下的一种特别令人震惊的形式。最近的PPG研究表明， 老年ADRD患者的死亡率过高，尤其是亚裔、黑人和西班牙裔人群， 生活在养老院的人，即使是在COVID-19低流行地区。交叉不平等 ADRD护理提供的范围从不同的风险暴露到可改变的风险， ADRD的发展，初步诊断和转诊，持续的治疗和支持，以及整个后期 包括临终关怀。从概念上讲，个人健康结果的决定因素将是 从社会生态学的角度来看， 相互作用的“系统”（个人、人际、组织、结构、社区和 政策）及其伴随的健康社会决定因素。因此，本次PPG更新提出了项目 关注这个模型的每个同心圆及其相互作用。项目1将探索国家级政策 异质性及其对符合条件养老院获得家庭和社区服务的影响 成人ADRD项目2将检验一个假设，即为成年人设立驻地服务协调员， 住在负担得起的老年人住房减少了不利的医疗保健服务的使用，并增加了家庭和 以社区为基础的服务使用与ADRD的低收入居民。项目3将探讨质量趋势 ADRD患者的初级保健，并确定可修改的政策，系统和实践层面的因素， 有助于更好的结果。最后，项目4将开发一种新的衡量供应商诊断偏差的方法， 急性护理环境中的测试顺序，并探讨诊断对患者轨迹的影响， ADRD。项目通过使用社会生态模型来研究 每个项目中审查的关键变量可以共同发挥作用，以改善成果和减少不平等， 并依靠共享的管理、数据和分析以及方法核心。

ABSTRACT Motivated by soaring spending and stagnating life expectancy, the first 20 years of this Program Project Grant (PPG) has focused on the causes and consequences of healthcare efficiency in the U.S. This work has advanced fundamental scientific knowledge regarding sources of inefficiency and has motivated significant changes in healthcare policy and delivery for millions of Americans. This competitive renewal responds to the NIA’s prioritization of Alzheimer’s disease and related dementia (ADRD)-related research and to eliminating health disparities by shifting the focus of this PPG to inequities in healthcare services and delivery for persons with ADRD and with a lens on racial inequities. This is a new framework from the work to-date produced by this PPG. Inequity is a particularly egregious form of healthcare inefficiency. Recent PPG research showed excess mortality among older adults with ADRD, especially for Asian, Black, and Hispanic populations and people living in nursing homes, even in areas with low COVID-19 prevalence. Intersectional inequities in ADRD care delivery run the gamut from differential exposure to the modifiable risks that contribute to development of ADRD, initial diagnosis and referral, ongoing treatment and support, and throughout later stages, including end-of-life care. Conceptually, the determinants of individual health outcomes will be documented among persons with ADRD from the social ecological perspective which recognizes nested ‘systems’ that interact with one another (individual, interpersonal, organizational, structural, community, and policy) and their attendant social determinants of health. This PPG renewal, therefore, proposes projects focusing on each concentric circle of this model and their interactions. Project 1 will explore state-level policy heterogeneity and its influence on access to home and community-based services for nursing home eligible adults with ADRD. Project 2 will test the hypothesis that having resident service coordinators for adults who live in affordable senior housing decreases adverse health care service use and increases home and community-based service use for low- income residents with ADRD. Project 3 will explore trends in the quality of primary care for people with ADRD and to identify modifiable policy-, system- and practice-level factors that contribute to better outcomes. Finally, Project 4 will develop a novel measure of bias in provider diagnostic test ordering in the acute care setting and explore the impact of diagnosis on the trajectory of patients with ADRD. Projects achieve synergy by using the social ecological model to examine how interactions among the key variables examined in each project could operate together to improve outcomes and reduce inequities, and by relying on shared administrative, data and analysis, and methodology cores.