A POPULATION BASED APPROACH TO IMPROVE OUTCOMES AFTER OUT-OF-HOSPITAL CARDIAC ARREST

摘要 在美国，院外心脏骤停（OHCA）是导致死亡的主要原因，影响超过30万公民 每年。医学研究所（IOM）最近发布了“提高心脏骤停生存率的策略： 行动的时刻，”说明“虽然在理解和治疗方面的突破令人印象深刻，但 始终如一地提供及时的干预措施和高质量的护理并不令人印象深刻。”IOM的工作 强调利益相关者之间的合作对于为OHCA患者提供最佳护理至关重要 缺乏。事实上，在人道主义事务协调厅的管理和成果方面存在着明显的地域差异， 主要的专业协会支持发展心脏骤停护理系统。OHCA生存率 给定的社区是其个人（例如年龄，共病状况），医院特征（例如， 有针对性的温度管理和早期心脏导管插入术的协议），以及组织 护理系统（例如，送往高容量中心的患者百分比）。在目前的结构中，问责制 结果取决于提供者或设施一级，但没有区域基准或激励措施来改善 OHCA在社区一级的成果。国际移民组织将总体人口健康定义为“所有人的健康 生活在一个特定的地缘政治区域”，并鼓励卫生系统，医院和付款人创建系统， 满足患者需求和改善全体人口健康的医疗服务。拟定研究 通过应用空间方法，为维持OHCA的医疗保险受益人开发新的归因方法， 确定自然发生的地理集群，而不是由卫生系统的隶属关系，而是由患者如何 获得紧急医疗服务。界定区域界限有助于对成果进行基准测试， 促进制定以人口为基础的激励措施。这种方法可以直接转化为实践 通过使用美国卫生与公众服务部部长所描述的基于人口的支付策略， 并由医疗保险和医疗补助服务中心实施。目标1将描述现有的模式 OHCA患者的医院利用率。目标2将确定现有的医院空间集群， OHCA社区的成员。目标3将确定风险调整后结果的变异性， 人口水平。这项工作提供了脚手架，使新的支付模式， 与IOM的全民健康愿景一致，美国心脏协会努力建立 区域保健系统，以及CMS改善人口健康的努力。我们的研究团队， 在卫生服务研究方法和应用于心脏骤停调查方面经验丰富，是独一无二的 我们有能力开展这些研究，这些研究将建立在我们目前在R56机制下开展的工作基础上。

Abstract Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the US, affecting over 300,000 citizens annually. The Institute of Medicine (IOM) recently released “Strategies to Improve Survival from Cardiac Arrest: A Time to Act,” stating “although breakthroughs in understanding and treatment are impressive, the ability to consistently deliver timely interventions and high-quality care is less than impressive.” The IOM’s work highlighted that the cooperation between stakeholders essential to deliver optimal care for patients with OHCA is lacking. Indeed, marked geographic variability exists in the management and outcomes of OHCA, and leading professional societies support the development of cardiac arrest systems of care. OHCA survival in a given community is a function of its individuals (e.g. age, comorbid conditions), hospital characteristics (e.g. protocols for targeted temperature management and early cardiac catheterization), and organization of the system of care (e.g. percent of patients taken to high volume centers). In the current structure, accountability for outcomes resides at the provider or facility level, but no regional benchmarks or incentives exist to improve OHCA outcomes at the community level. The IOM defines total population health as “the health of all persons living in a specified geopolitical area” and encourages health systems, hospitals, and payers to create systems of care that meet the needs of patients and improve the health of the total population. The proposed study develops a new attribution method for Medicare beneficiaries sustaining OHCA by applying spatial methods to identify naturally occurring geographic clusters defined not by health system affiliation, but by how patients access healthcare for emergencies. Defining regional boundaries allows for benchmarking of outcomes, and facilitates development of population-based incentives. This approach can be directly translated into practice by using population-based payment strategies as described by the U.S. Secretary of Health & Human Services and implemented by the Centers for Medicare & Medicaid Services. Aim 1 will describe the existing patterns of hospital utilization for patients with OHCA. Aim 2 will identify existing spatial clusters of hospitals that treat members of a community with OHCA. Aim 3 will determine variability in risk-adjusted outcomes at the population level. This work provides the scaffolding to enable the construction of new payment models that are consistent with the IOM vision of total population health, the American Heart Association’s efforts to build regional systems of care, and the CMS efforts to improve population health. Our research team, richly experienced in health services research methods and application to cardiac arrest investigations, is uniquely positioned to conduct these studies, which will build on our current work under an R56 mechanism.