Addressing Racial/Ethnic Disparities in Stroke Care Access Using Hospital Transfer Networks

项目总结 中风通常发生在老年患者中，是导致长期残疾的主要原因。伤残与死亡 可通过及时的再灌注干预(即静脉溶栓和 血管内血栓切除术)和高质量的中风中心护理。不幸的是，来自少数族裔或 服务不足的人群获得再灌注干预和急性中风专业知识的机会较少。这是 这在很大程度上是因为中风中心--最有能力照顾中风患者的医院--并不是 地理分布与患者居住的地方相匹配，许多患者最初呈现给较小的、非 中风中心医院。已经做了有价值的工作来提高第一家较小医院的能力， 例如，通过远程中风的扩展。然而，对中风最有效的干预措施是 需要转移。血管内血栓切除术仅在具有先进能力的医院可用，以及 在获得这一非常有效的干预措施方面，存在着明显的地域和种族/族裔差异。 优化的医院间中风患者转移系统可能是更公平地获得 高质量的中风护理。虽然造成机会和成果差距的许多因素相对较多 固定的(例如，患者人口统计或医院位置)，医院间患者转移的过程是动态的 并受到干预。移交的决定，以及移交决定的及时性和目的地 可以影响到明天的改善结果。然而，影响患者转移的因素很多。 决定。在这项混合方法研究中，我们使用全州范围内的所有付款人索赔数据来研究Over的网络 通过340家加州医院的连接，了解中风患者转院之间的关系 转院决定以及患者接触和结果方面的差异。我们将应用来自网络的方法 科学，非常适合描述和研究动态的、多层次的、相互依赖的结构 中风病人转送网络。我们将开发和应用网络社区检测的新方法来 确定通过病人转移密切联系的医院群，并研究种族/民族 医院集群的组成与集群中与中风相关的能力以及集群如何 随时间变化(目标1)。我们将量化患者层面的种族和民族差异，以获得中风和 在医院联网一级确定与差异有关的结果和因素(目标2)。然后，在 确定积极和消极偏差的医院集群(作为实现高水平的 可获得性和低差距)，我们将使用定性方法来确定可扩展的战略，以减少不平等 在卒中机会和结果方面(目标3)。我们相信，这些解决方案将对卫生系统有价值 旨在确保所有中风患者获得更好的机会和结果的领导人和政策制定者。在更广泛的层面上 我们的发现将适用于各种条件下的医院转送网络(例如， 创伤、急性心肌梗死)，以实现更公平的护理机会和改善患者预后。

PROJECT SUMMARY Stroke occurs commonly in older patients and is a leading cause of long-term disability. Disability and death from stroke can be reduced with timely reperfusion interventions (i.e., intravenous thrombolysis and endovascular thrombectomy) and high-quality stroke center care. Unfortunately, patients from minority or underserved populations have less access to reperfusion interventions and acute stroke expertise. This is largely because stroke centers – the hospitals best equipped to care for stroke patients – are not geographically distributed to match where patients live and many patients initially present to smaller, non- stroke center hospitals. Valuable work has been done to improve the capabilities of that first, smaller hospital, for example through the expansion of telestroke. However, the most effective interventions for stroke will require transfer. Endovascular thrombectomy is only available at hospitals with advanced capabilities, and there are significant geographic and racial/ethnic disparities in access to this highly efficacious intervention. An optimized system of interhospital stroke patient transfers could be a solution to more equitable access to high-quality stroke care. While many factors contributing to disparities in access and outcomes are relatively fixed (e.g., patient demographics or hospital locations), the process of interhospital patient transfers is dynamic and subject to intervention. The decision to transfer, and the timeliness and destination of that transfer decision can be influenced toward improved outcomes tomorrow. Yet there are many factors influencing patient transfer decisions. In this mixed-methods study, we use statewide, all-payer claims data to study the network of over 340 California hospitals connected through stroke patient transfer to understand the relationship between transfer decisions and disparities in patient access and outcomes. We will apply methods from network science, which are ideally suited to characterize and study the dynamic, multi-level, interdependent structure of the stroke patient transfer network. We will develop and apply new methods in network community detection to identify clusters of hospitals closely connected through patient transfer and to study how the racial/ethnic composition of hospital clusters is associated with stroke-related capabilities in the cluster and how clusters change over time (Aim 1). We will quantify patient-level racial and ethnic disparities in stroke access and outcomes and identify factors at the hospital cluster-level associated with disparities (Aim 2). Then, upon identifying clusters of hospitals that are positive and negative deviants (as outliers in achieving high levels of access and low disparities), we will use qualitative methods to identify scalable strategies to reduce inequalities in stroke access and outcomes (Aim 3). We believe that that these solutions will be valuable to health system leaders and policy makers aiming to ensure better access and outcomes for all stroke patients. On a broader level, our findings will be applicable to hospital transfer networks across a broad range of conditions, (e.g., trauma, acute myocardial infarction) to achieve more equitable access to care and improved patient outcomes.