Racial and Ethnic Health Disparities Due to Ambulance Diversion

 描述(由申请人提供)：2007年，医学研究所(IOM)将救护车分流(AD)--急诊科暂时关闭的做法--描述为“与优质医疗服务相反”，并呼吁“消除”这种做法。然而，A仍然存在，在2003年发布的上一次调查中，45%的急诊室和70%的城市急诊室报告了AD。AD与较高的死亡率、延迟治疗和其他不良后果有关。到目前为止，AD还没有被研究过，它有可能加剧按种族/族裔和收入划分的差距。广告还可能增加医疗成本。然而，目前关于AD影响的文献是基于方便抽样的数据，并受到缺乏实验证据的限制。2009年1月1日，马萨诸塞州成为第一个也是迄今为止第一个禁止广告的州。将国家强制实施的禁令视为一项自然实验，我们建议估计AD对获取、结果和成本的因果影响，重点是种族/民族和收入的潜在差异影响。为了更好地在整体患者护理的环境中了解救护车的使用和AD，我们将基于医疗保险管理数据开发一个全国救护车使用的纵向数据库。使用纵向患者记录，这些数据将更适合于检查救护车使用、结果和AD对不同患者的影响的决定因素。我们将重点关注患有慢性心血管或肺部疾病的老年人。我们将确定一个全国队列，其中包括所有66岁或以上的联邦医疗保险受益人(N=1,000,000)的分层随机抽样，并从马萨诸塞州进行超抽样，并获得2006-2012年所有医疗保健利用的数据，包括救护车和急诊室就诊。鉴于住宅地点在检验救护车和急症室使用情况时的首要地位，我们将按种族/民族和居住邮政编码对样本进行分层，以便对来自同一地区的不同患者进行比较。对于波士顿居民子集(波士顿队列)，我们将合并来自波士顿紧急医疗服务(EMS)2006-2012年的数据，以用于EMS特定的结果衡量。我们的具体目标是评估：(1)救护车使用和依赖的发生率，(2)不同种族/民族和收入的救护车运送结果的差异，以及(3)马萨诸塞州AD禁令对救护车运送结果和其他未用救护车运送的ED患者的影响。医学研究所(IOM)强调了EMS实践的“有限”研究和知识基础。使用国家范围的新数据，这项研究将对这一证据基础做出重大贡献，并为AD的公共政策提供信息，不仅涉及其对临床结果的影响，还涉及其对差异的影响。

 DESCRIPTION (provided by applicant): In 2007, the Institute of Medicine (IOM) characterized ambulance diversion (AD), the practice by which Emergency Departments (EDs) are temporarily closed, as "antithetical to quality medical care" and called for its "elimination". Nevertheless, A persists, with 45% of EDs and 70% of urban EDs reporting AD in the last published survey in 2003. AD has been associated with higher mortality, delayed treatment, and other adverse outcomes. Not examined hitherto, AD has the potential to exacerbate disparities by race/ethnicity and income. AD may also increase healthcare costs. However, the current literature on the impact of AD is based on data from convenience sampling and is limited by a dearth of experimental evidence. On 1/1/2009, Massachusetts became the first, and to date only, state to ban AD. Treating the state-imposed ban as a natural experiment, we propose to estimate the causal impact of AD on access, outcomes, and cost, focusing on the potentially differential effects by race/ethnicity and income. To better understand ambulance use and AD within the milieu of overall patient care, we will develop a national longitudinal database of ambulance use based on Medicare administrative data. Using longitudinal patient records, this data will be better suited to examine the determinants of ambulance use, outcomes, and the impact of AD across diverse patients. We will focus on older adults with a chronic cardiovascular or pulmonary condition. We will identify a national cohort of a stratified random sample of all Medicare beneficiaries aged 66 or older (N=1,000,000), with an oversample from Massachusetts, and obtain data on all healthcare utilization, including ambulance and ED visits, from 2006-2012. Given the primacy of residential location in examining ambulance and ED use, this sample will be stratified by race/ethnicity and residence zip code to enable comparison of diverse patients from the same area. For the subset of Boston residents (Boston cohort) we will merge data from the Boston Emergency Medical Services (EMS) from 2006-2012 for EMS-specific outcome measures. Our specific aims are to evaluate: (1) incidence of ambulance use and reliance, (2) differences by race/ethnicity and income in ambulance transport outcomes, and (3) impact of Massachusetts AD ban on outcomes of ambulance transport and other ED patients not transported by ambulance. The Institute of Medicine (IOM) has highlighted the "limited" research and knowledge base of EMS practices. Using novel data with national scope, this study will make significant contributions to this evidence base and inform public policy on AD regarding not only its impact on clinical outcomes, but also, its impact on disparities.