Impact of Rural Hospital Payment and Delivery Reform on Geographic Disparities in Cancer Surgery

项目摘要 农村地区的癌症患者获得专门护理的机会更有限， 治疗，并有较差的结果比他们在非农村地区的同行。近年来，许多 农村医院已经关闭，剩余的农村医院中有很大一部分陷入财政困境， 关闭的风险，加剧了农村患者的护理障碍。与此同时，有证据表明， 在医院进行的手术与改善的健康结果（包括死亡率）相关， 努力使外科护理区域化。虽然区域化的好处有据可查，但 将癌症手术转移到大容量中心，给农村地区的患者、外科医生和医院带来了挑战。 社区.在这种复杂的背景下，宾夕法尼亚州发起了宾夕法尼亚州农村 健康模式（PRHM），一项旨在为医院提供可预测收入流的创新计划 通过全球预算，并鼓励参与医院重新设计护理服务，以最好地满足需求 他们的社区。该项目将评估PRHM对获得和相关成果的影响。 癌症手术首先，我们将研究PRHM对区域癌症手术交付的影响 通过检查癌症患者接受手术的医院的位置和特点， 使用全州范围内的出院数据。通过将支付与数量脱钩，PRHM改变了激励机制， 提供者在当地进行手术，而不是将患者转诊到区域中心。我们假设 PRHM医院服务地区的患者将更有可能被转诊到高容量中心， 其他农村医院市场。其次，我们将评估PRHM对癌症手术访问的影响 以及使用关联的出院和癌症登记数据的结果。PRHM强调护理的变化 提供以改善人口健康为目标的服务，重点是获得专科护理。我们 假设在PRHM医院服务的地区，手术癌症患者可能会在以下方面得到改善： 接受推荐的癌症手术，手术时间和相关的健康结果，包括死亡率和 再入院第三，我们将使用定性的方法来了解PA农村卫生模式的实施情况 过程，包括其对资源利用，医院能力，人员配备，护理服务和财务的影响 激励供应商。我们将与关键线人和社区焦点小组进行访谈， 持份者在源自实施科学的全面概念模型的指导下，我们将 精细地评估PRHM成功或失败影响医院流程的机制， 癌症外科治疗的结果。随着目标医院服务地区的人口继续老龄化， 癌症发病率和对高质量外科护理的需求将增加。这方面的经验教训将是 与农村医院的替代支付模式和满足外科手术需求高度相关 美国各地农村社区的癌症患者。

Project Summary Cancer patients in rural areas have more limited access to specialized care, are less likely to receive certain treatments, and have poorer outcomes than their counterparts in non-rural areas. Over recent years, many rural hospitals have closed and a high proportion of remaining rural hospitals are in financial distress and at risk for closure, exacerbating barriers to care for rural patients. At the same time, evidence that the volume of surgeries performed in a hospital is associated with improved health outcomes, including mortality, has led to efforts to regionalize surgical care. Although the advantages of regionalization are well documented, referring cancer surgeries to high-volume centers presents challenges for patients, surgeons, and hospitals in rural communities. Against this complex backdrop, the state of Pennsylvania has initiated the Pennsylvania Rural Health Model (PRHM), an innovative program designed to provide hospitals with predictable revenue streams through global budgets and encourage participating hospitals to redesign care delivery to best meet the needs of their communities. This project will assess the impact of the PRHM on access to and outcomes associated with cancer surgery. First, we will examine the impact of the PRHM on regional cancer surgery delivery patterns by examining the location and characteristics of hospitals at which cancer patients receive surgery using statewide hospital discharge data. By decoupling payment from volume, PRHM changes the incentives for providers to perform surgeries locally versus referring patients to regional centers. We hypothesize that patients in areas served by PRHM hospitals will be more likely to be referred to high-volume centers than those in other rural hospital markets. Second, we will assess the effect of the PRHM on cancer surgery access and outcomes using linked discharge and cancer registry data. The PRHM emphasizes changes in care delivery that target improvements in population health, with a focus on access to specialty care. We hypothesize that surgical cancer patients in areas served by PRHM hospitals may experience improvements in receipt of recommended cancer surgery, time to surgery, and related health outcomes, including mortality and readmissions. Third, we will use qualitative methods to understand the PA Rural Health Model implementation process, including its impacts on resource utilization, hospital capabilities, staffing, care delivery, and financial incentives for providers. We will conduct interviews with key informants and focus groups with community stakeholders. Guided by a comprehensive conceptual model derived from implementation science, we will granularly assess the mechanisms by which PRHM succeeded or failed to affect hospital processes and outcomes for surgical cancer care. As the population in areas served by targeted hospitals continues to age, cancer incidence and the demand for high-quality surgical care will increase. Lessons from this context will be highly relevant for informing alternative payment models in rural hospitals and addressing the needs of surgical cancer patients in rural communities throughout the United States.