Effect of Bypass Policies on Stroke Treatment in a National Sample of Medicare Beneficiaries

项目摘要 对于有卒中症状的患者，静脉注射阿替普酶进行快速住院治疗对于 上级患者结局。为了快速静脉注射阿替普酶，几个县实施了旁路手术， 政策要求护理人员绕过当地急诊室，直接将病人送往 中风中心然而，科学证据表明，该政策导致有效，更高的质量和公平 对中风患者的护理有限。我们提出的研究将测试政策对静脉注射阿替普酶使用的影响，30- 日死亡率和短期和长期功能独立性。如果观察到更高的效益，该政策可能 扩大到非政策县。在我们的初步工作（由AHRQ K 08 HS 17965资助）中，我们使用了 两个县的前后设计，以测试政策对治疗的影响。虽然我们的研究显示 在一个县的治疗，评价仅限于两个城市县，并没有控制世俗 趋势拟议的研究将利用以下三个目标解决上述限制。一是 检查旁路政策是否导致全县静脉注射阿替普酶使用、死亡率和短期 长期功能独立。对于这个分析，我们将利用自然实验， 在美国，各县在八年期间（2006-2013）的不同时间实施了该政策。 我们将确定896个县与政策，并将其匹配1792个县没有绕道政策（总人数 =2688），并使用差异中的差异方法来检查政策的有效性。二是 将检查县因素（例如，政策组成部分的变化，城市/郊区/农村县）是 与对结果的不同影响有关。第三，我们将使用多个案例研究设计， 对24个州（72个供应商访谈）进行深入评价的方法， 调查和文件分析县中风协议，解释政策效果，并确定 政策效果的推动者。我们将使用一种解释性序贯设计，一种混合方法， 将目标1和2中的定量数据与目标3中的定性数据结合起来， 显示以呈现结果。这项研究是重要的，因为它将提供一个准确的估计， 政策对患者预后的影响。该研究也符合AHRQ的使命，即研究使用 比较有效性方法，使用大型数据库进行定量评估，特别强调分 人口，如城乡差异和定性审查，以确定最佳的 县的做法。

Project Summary For a person with stroke symptoms, rapid hospital-based treatment with intravenous alteplase is critical for superior patient outcomes. To rapidly deliver intravenous alteplase, several counties implemented a bypass policy that requires paramedics to bypass the local emergency departments and directly route patients to stroke centers. However, scientific evidence that the policy results in effective, higher quality and equitable care to stroke patients is limited. Our proposed study will test policy's effect on intravenous alteplase use, 30- day mortality and short- and long-term functional independence.. If higher benefit is observed, the policy could be extended to non-policy counties. In our preliminary work (funded by AHRQ K08 HS17965), we used a before-after design of two counties to test the policy's effect on treatment. Although our work showed higher treatment in one of the counties the evaluation was limited to two urban counties and did not control for secular trends. The proposed study will address the above limitations using the following three aims. First, we will examine if the bypass policy leads to increase in countywide intravenous alteplase use, mortality and short-and long term functional independence. For this analysis, we will leverage on the natural experiment that happened in the US in which counties implemented the policy at different times during an eight-year period (2006-2013). We will identify 896 counties with the policy and match them 1792 counties without the bypass policy (total n =2688) and use a difference-in-differences approach to examine the effectiveness of the policy. Second, we will examine if county factors (e.g., variation in policy components, urban/suburban/rural counties) are associated with differential effects on outcomes. Third, we will use a multiple case study design, a qualitative approach to perform in-depth evaluation of 24 counties (72 provider interviews) using interviews, county surveys and document analysis of the county stroke protocols, to explain the policy effect and identify the enablers of the policy's effect. We will use an explanatory sequential design, a mixed-methods approach, to integrate the breath of the quantitative data in aims 1 and 2 with the qualitative data in aim 3 and use a joint display to present the findings. This study is significant because it will provide an accurate estimate of the policy effect on patient outcomes. The study also fits with AHRQ' mission on study of healthcare models using comparative effectiveness methods, quantitative evaluation using large databases, special emphasis on sub- population such as urban-rural differences and a qualitative examination with the goal of identifying best practices for the counties.