Variations in Use of Heart Replacement Therapies Among Patients with Advanced Heart Failure

项目总结/摘要 心脏替代疗法（即，心脏移植和左心室辅助装置）可以改善晚期 心力衰竭患者的发病率、死亡率和生活质量。然而，这些疗法与两者都有关。 高风险和潜在的高回报。晚期心力衰竭患者接受心脏置换术的途径 治疗取决于3个关键步骤：（1）转诊到高级心力衰竭中心，（2）临床评估 在中心，和（3）由多学科选择委员会的情况下审查。该途径是异质性的 导致治疗使用不足和过度使用。迫切需要研究在哪里 以及为什么存在这些使用上的差异，并实施减少护理中不必要的差异的解决方案。 所提出的研究的基本原理是，如果我们能够理解导致 在心脏替代疗法的三个关键步骤中，我们可以制定标准化的 确保最有可能从这些治疗中获益的心力衰竭患者能够获得 那些不太可能符合条件的人可以迅速转向其他最适合他们的治疗方法。 他们的需求和偏好。这个职业发展奖包括三个互补的目标。目标1将 使用Medicare索赔，定量评估三个步骤中每个步骤的地理差异程度， 达特茅斯阿特拉斯医院转诊区域。目标2将通过执行以下操作定性评估变化原因： 对高级心力衰竭中心的选择会议和利益相关者访谈进行批判性审查， 根据目标1的发现选择。Aim 3将使用德尔菲小组对导致不必要的 变化，并提出潜在的解决方案，以减少变化。更深入地了解心脏的变化 替代疗法的使用加上专家审查的主要问题的建议解决方案将导致 R 01干预试验，将解决一个或多个可改变的因素，并将有助于减少不必要的 心脏替代疗法的使用变化。申请人是一名高级心力衰竭心脏病专家， 提出了一个为期五年的职业发展计划，以补充研究建议。这个合并在 拉里艾伦（小学），丹马特洛克，和弗雷德Masoudi，全国知名的密切指导 心血管结局研究人员，具有晚期心力衰竭、索赔数据、定性 研究和共同决策。候选人与她的导师建立了富有成效的关系， 四份已发表的手稿和两份正在编写的手稿，并有一个支持性的体制环境。补充 她在公共卫生硕士培训之前，候选人已经制定了详细的教学计划，其中包括 医疗保险索赔数据使用、地理分析、定性方法和传播方面的培训， 执行科学。候选人的长期目标是提高公平，明智，以病人为中心 使用心脏替代疗法治疗晚期心力衰竭患者。拟议的研究，其中 作为申请人实现长期目标的关键第一步，意义重大，因为它将填补 现有的知识差距，以帮助减少使用心脏替代疗法的变化。

PROJECT SUMMARY/ ABSTRACT Heart replacement therapies (i.e., heart transplants and left ventricular assist devices) can improve advanced heart failure patients’ morbidity, mortality, and quality of life. However, these therapies are associated with both high risks and potentially high rewards. An advanced heart failure patient’s path to receiving heart replacement therapies is dependent on 3 critical steps: (1) referral to an advanced heart failure center, (2) clinical evaluation at the center, and (3) case review by a multidisciplinary selection committee. This pathway is heterogeneous across the country leading to both underuse and overuse of therapies. There is an urgent need to study where and why these variations in use exist and to implement solutions that reduce unwarranted variations in care. The rationale that underlies the proposed research is that if we can understand the factors that lead to variations in heart replacement therapies at each of the three critical steps, we can develop standardized processes to ensure that heart failure patients who are most likely to benefit from these therapies have access to them, and those who are unlikely to qualify can move quickly to other treatment approaches most suited to their needs and preferences. This career development award includes three complementary aims. Aim 1 will quantitatively assess the degree of geographic variation at each of the three steps using Medicare claims and the Dartmouth Atlas hospital referral regions. Aim 2 will qualitatively assess reasons for variation by performing critical reviews of selection meetings and stakeholder interviews at advanced heart failure centers that are chosen based on findings from Aim 1. Aim 3 will use Delphi panels to rank factors contributing to unwarranted variation and propose potential solutions to reduce variation. A deeper understanding of variations in heart replacement therapy use coupled with expert-vetted proposed solutions for the leading problems will result in a R01 intervention trial that will address one or more of the modifiable factors and will help reduce unwarranted variations in use of heart replacement therapies. The applicant, an advanced heart failure cardiologist, proposes a five-year career development program to complement the research proposal. This incorporates close mentoring with Drs. Larry Allen (primary), Dan Matlock, and Fred Masoudi, nationally-renowned cardiovascular outcomes researchers with expertise in advanced heart failure, claims data, qualitative research, and shared decision-making. The candidate has built productive relationships with her mentors with four published manuscripts and two in progress and has a supportive institutional environment. To supplement her prior Masters in Public Health training, the candidate has developed a detailed didactic plan that includes training in Medicare claims data use, geographic analyses, qualitative methodology, and dissemination and implementation science. The candidate’s long-term goal is to improve equitable, judicious, patient-centered use of heart replacement therapies for patients with advanced heart failure. The proposed research, which serves as a key first step towards the applicant reaching her long-term goal, is significant because it will fill the existing gaps in knowledge to help reduce variations in use of heart replacement therapies.