Cardiac care in specialty and general hospitals

描述(申请人提供)：最近出现的心脏专科医院引起了广泛的争议。支持者建议这样的医院提供更高质量和更低成本的医疗服务，而批评者则认为专科唾液“精挑细选”的患者病情较轻，利润更高，患者预后没有明显改善。以前比较专科心脏病医院和综合医院的研究只检查了有限数量的条件和程序，纳入的专科医院相对较少，并且没有检查专科医院对同一医疗保健市场中的综合医院的影响。这些初步研究的结果与一些研究结果不一致，这些研究表明专科医院的结果有所改善，而另一些研究则没有改善。此外，这些初步研究完全基于行政数据来源，没有利用临床登记，尽管这种方法具有潜在的优势。拟议研究的具体目的是比较在专科心脏病医院和竞争对手的综合医院接受护理的患者的结果，并检查专科医院对相同市场中的综合医院的影响。这项为期四年的研究将涉及两个行政数据来源(国家医疗保险和州一级索赔数据)的分析，以及两个专有临床登记(胸科外科学会国家数据库和国家心血管数据登记)的补充。这项研究将利用管理和临床数据，通过检查在更多的专业心脏医院接受广泛疾病治疗的患者的结果，解决先前研究的局限性，包括急性心肌梗死和充血性心力衰竭患者，以及接受经皮冠状动脉介入治疗、冠状动脉旁路移植手术和瓣膜置换手术的患者。对于每一种诊断，心脏病专科医院的死亡率和并发症发生率将与位于与专科医院相同的医疗市场的竞争综合医院的死亡率和并发症发生率进行比较。将使用三种互补的方法来最小化选择偏差(分层线性模型、倾向评分和工具变量)，并针对患者级别、医院级别和市场级别的重要混杂因素进行调整。其他分析将评估新的心脏专科医院对位于相同医疗保健市场内的竞争综合医院的心脏容量和患者结局的影响。这些分析将提供有关心脏病专科医院向政策制定者、付款人、提供者和患者提供的相对护理质量的急需信息。

DESCRIPTION (provided by applicant): The recent emergence of specialty cardiac hospitals has generated widespread controversy. Proponents suggest that such hospitals deliver higher quality and lower cost care, while critics contend that specialty lospitals "cherry pick" lower severity and more profitable patients with no demonstrable improvements in patient outcomes. Prior studies comparing specialty cardiac and general hospitals have examined a limited number of conditions and procedures, have included relatively few specialty hospitals, and have not examined the impact of specialty hospitals on general hospitals in the same healthcare markets. The results of these preliminary studies have been inconsistent with some studies demonstrating improved outcomes in specialty hospitals and others demonstrating no improvement. Moreover, these initial studies have been based exclusively upon administrative data sources and have not utilized clinical registries despite the potential advantages of this approach. The specific aims of the proposed research are to compare the outcomes of patients receiving care in specialty cardiac and competing general hospitals and to examine the impact of specialty hospitals on general hospitals in the same markets. This four-year study will involve the analysis two administrative data sources (national Medicare and state-level claims data) supplemented by two proprietary clinical registries (the Society for Thoracic Surgeons National Database and the National Cardiovascular Data Registry). The research will address the limitations of prior studies by examining outcomes of patients treated in a larger number of specialty cardiac hospitals for a broad spectrum of conditions, including patients with acute myocardial infarction and congestive heart failure and patients undergoing percutaneous coronary interventions, coronary artery bypass graft surgery, and valve replacement surgery using both administrative and clinical data. For each diagnosis, mortality and complication rates in specialty cardiac hospitals will be compared with mortality and complication rates in competing general hospitals located within the same healthcare market as the specialty hospitals. Three complementary methods will be used to minimize selection bias (hierarchcial linear models, propensity scores, and instrumental variables) and adjust for important patient-level, hospital-level, and market-level confounders. Additional analyses will assess the impact of new specialty cardiac hospitals on the cardiac volumes and patient outcomes of competing general hospitals located within the same healthcare markets. Together these analyses will provide much needed information on the relative quality of care provided by specialty cardiac hospitals to policy makers, payors, providers and patients.