Explaining Rising Heart Failure Mortality in Medicare

解释医疗保险中不断上升的心力衰竭死亡率

• 批准号: 10437732
• 负责人: Rishi Kumar Wadhera
• 金额: $ 17.25万
• 依托单位: BETH ISRAEL DEACONESS MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-07-15 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10437732
• 关键词: Accident and Emergency department; Advisory Committees; Affect; Age; Area; Automobile Driving; Award; Awareness; Biostatistical Methods; Cardiovascular system; Caring; Clinical; Clinical Investigator; Complex; Data; Decision Making; Elderly; Emergency department visit; Financial Hardship; Foundations; Goals; Health Policy; Heart failure; Hospitalization; Hospitals; Incentives; Individual; Inpatients; Interview; Length of Stay; Low income; Medicare; Medicare claim; Medicine; Mentors; Neighborhoods; Outcome; Outcomes Research; Outpatients; Patient Care; Patient Preferences; Patient Triage; Patient-Focused Outcomes; Patients; Patterns of Care; Perception; Physicians; Policies; Population; Poverty; Prevalence; Program Development; Public Health; Qualitative Methods; Quality of Care; Reporting; Research; Research Personnel; Resources; Risk; Risk Factors; Site; Social Change; Structure; Surveys; Testing; Time; United States; Vulnerable Populations; Work; acute care; base; beneficiary; care delivery; care outcomes; career; career development; clinical care; deprivation; design; disadvantaged population; experience; federal policy; financial incentive; follow-up; high risk; hospital readmission; improved; improved outcome; innovation; insight; large datasets; mortality; novel strategies; older patient; policy implication; pressure; profiles in patients; programs; readmission rates; residence; skills; social; social disadvantage; social vulnerability; trend

! ! PROJECT(SUMMARY/ABSTRACT( The clinical and financial burden of heart failure (HF) among older adults in the United States is high, with over 400,000 hospitalizations and $30 billion in spending annually. After a decade of steady improvement in short- term mortality among older adults hospitalized with HF, mortality within 30 days of hospital discharge is now increasing in this population. Little is known, however, about the factors driving this concerning trend. This study proposes to use administrative and qualitative data to evaluate patient, hospital, and policy level factors that explain rising mortality. In Aim 1, we will use Medicare data to determine if increasing clinical and/or social risk among older adults hospitalized with HF, or worsening hospital care quality, explain recent trends in mortality. In Aim 2, we will examine whether the Hospital Readmissions Reduction Program (HRRP) - a federal policy that intended to improve HF care by financially penalizing hospitals with high 30-day readmission rates – has incentivized inappropriate post-discharge care strategies (i.e. avoiding indicated readmissions) that have been associated with increased mortality. Our preliminary data suggest that the rise in mortality is being driven by patients with HF who are not readmitted to the hospital, providing initial support for this hypothesis. In Aim 3, we will use semi-structured physician interviews to understand if their decision-making regarding the care of HF patients has changed since HRRP. In addition, we will interview patients with HF to explore their awareness and perception of this policy. These interviews will also be used to gather preliminary data on potential strategies to improve post-discharge HF care. The overarching goal of this proposal is to understand why short-term mortality among older adults with HF is rising in the United States, which may have significant clinical and policy implications. The first two aims of this analysis will inform whether more resources should be allocated to sites that care for clinically high-risk or socially disadvantaged populations and if current federal policies (HRRP) should be redesigned or eliminated. The third aim will lay the foundation for future research to develop and test novel strategies, based on physician and patient preferences, to improve post-discharge HF care. This research will be accomplished in the setting of a comprehensive career development program designed to provide Dr. Wadhera, an early career investigator and cardiologist, with the skills needed to become an independent investigator in cardiovascular medicine and health policy. His long-term career goal is to use large datasets at the population level, and qualitative methods at the individual level, to comprehensively evaluate the impact of health policies on cardiovascular care and outcomes. An outstanding mentoring team and advisory committee of established clinical investigators in the fields of cardiovascular medicine, outcomes research, health policy, and advanced biostatistical and qualitative methods will guide Dr. Wadhera in his transition to independence over the course of the award period. !

! ! 项目（概要/摘要） 美国老年人心力衰竭（HF）的临床和经济负担很高， 每年有40万人住院治疗，花费300亿美元。在短短十年的稳步改善后- 在因HF住院的老年人中，出院后30天内的死亡率 在这一人口增长。然而，人们对推动这一令人担忧的趋势的因素知之甚少。这 研究建议使用行政和定性数据来评估患者、医院和政策层面的因素 这就解释了死亡率的上升。在目标1中，我们将使用医疗保险数据来确定是否增加临床和/或社会 老年人因HF住院的风险或医院护理质量恶化，解释了最近的趋势， mortality.在目标2中，我们将研究医院再入院减少计划（HRRP）-一个联邦 旨在通过对30天再入院率高的医院进行经济处罚来改善HF护理的政策- 鼓励了不适当的出院后护理策略（即避免指定的再入院）， 与死亡率增加有关。我们的初步数据显示死亡率的上升 没有再次入院的HF患者，为这一假设提供了初步支持。在Aim中 3、我们将使用半结构化的医生访谈来了解他们关于护理的决策， 自HRRP以来，HF患者发生了变化。此外，我们将采访HF患者，以探讨他们的 对这一政策的认识和理解。这些访谈还将用于收集以下方面的初步数据： 改善出院后HF护理的潜在策略。本提案的首要目标是了解 为什么在美国老年HF患者的短期死亡率正在上升，这可能有显着的 临床和政策影响。本分析的前两个目标将告知是否应增加资源， 分配给护理临床高风险或社会弱势群体的站点，如果当前联邦 应重新设计或取消人力资源政策。第三个目标将为今后的研究奠定基础， 根据医生和患者的偏好，开发和测试新的策略，以改善出院后HF 在乎本研究将在建立一个全面的职业发展计划中完成 旨在为早期职业调查员和心脏病专家Wadhera博士提供所需的技能， 成为心血管医学和健康政策的独立调查员。他的长期职业目标是 在人口层面使用大型数据集，在个人层面使用定性方法， 全面评估卫生政策对心血管护理和结果的影响。一位杰出 由心血管领域的知名临床研究者组成的指导团队和咨询委员会 医学，成果研究，卫生政策，先进的生物统计和定性方法将指导博士。 Wadhera在裁决期间向独立过渡。 !