Effect of home care agency providers and visits of heart failure patient outcomes

描述（由申请人提供）：心力衰竭（HF）是美国人和为他们服务的医疗保健系统的高负担疾病-心力衰竭是65岁以上患者住院的主要原因，在指标住院时间的6个月内再住院率高达65%。心力衰竭患者的功能状态也有进行性下降。急性期后家庭随访是减轻美国医疗保健系统心力衰竭负担的一种策略。家庭保健机构是心力衰竭患者急性期后最常见的护理提供者。然而，很少有证据表明，对于接受家庭保健的心衰患者，减少再住院和改善功能状态结果的最有效方法。在家庭保健方面，很少有关于就诊次数和结果之间关系的研究，结果也很模棱两可。因此，本研究的目的是确定接受家庭保健的心衰患者再住院和功能下降的预测因素，并确定特定的护理方法（更高的就诊强度）是否与降低再住院和功能状态下降有关，从而可能减轻心衰患者个体和医疗保健系统的负担。安徒生行为模型提供了概念框架。本研究采用大型数据库设计，将家庭医疗保健临床数据（OASIS）与医疗保险患者的理赔数据（家庭健康和医院）、县级（疗养院、家庭医疗保健机构和医院的数量以及确定城乡性质的地点）和机构级（利润状况和医院隶属关系）数据联系起来。医院数据将包括家庭保健服务开始前6个月和开始后6个月，提供更全面的医院使用情况。关联数据集将使我们能够确定与再住院和功能状态下降相关的患者因素，并检查较高的就诊强度是否与更少的再住院、更少的再住院天数、更长的再住院时间和更少的功能状态下降相关。根据2003年的数据，我们预计有100,000名符合条件的心衰患者，其中11,000人将再次住院，其中20,000人将出现功能状态下降。由于数据的嵌套特性，分析将使用多层次建模方法。这项研究的创新之处在于，它使用了所有接受医疗保险家庭医疗保健的心衰患者的国家数据，并使用了县级和机构一级的数据，此外还使用了患者一级的数据，这在此人群中是前所未有的。子样本分析将包括最年长的老人（50 - 85岁）和少数民族。因此，本研究信息的临床应用直接关系到家庭保健从业人员设计护理实践（就诊次数）以及为心衰患者订购家庭保健服务的医生和医院。

DESCRIPTION (provided by applicant): Heart failure (HF) is a high burden condition for Americans and the health care system serving them-heart failure is the leading cause of hospitalization for patients over 65 with rates of rehospitalization as high as 65% within 6 months of the index hospital stay. Patients with heart failure also have progressive decline in functional status. Post-acute follow up in the home is one strategy to reduce the burden of heart failure on the US health care system. Home health care agencies are the most common type of post-acute care provider for patients with heart failure. Yet there is little evidence on the most effective ways to reduce rehospitalization and improve functional status outcomes for HF patients receiving home health care. In home health care, little research has been done on the relationship between the numbers of visits and outcomes and the results have been equivocal. Thus, the purpose of the present study is to determine factors predictive of rehospitalization and functional decline in HF patients receiving home health care and identify whether specific approaches to delivery of care (higher visit intensity) is associated with lower rehospitalization and functional status decline, potentially reducing the burden of HF on individual patients and the health care system. The Andersen Behavioral Model provides the conceptual framework. The study employs a large data base design linking home health care clinical data (OASIS) with claims data (home health and hospital), county level (numbers of nursing homes, home health care agencies, and hospitals and location for determining urban-rural nature) and agency level (profit status and hospital affiliation) data for patients with Medicare. Hospital data will include 6 months prior to and 6 months following the initiation home health care services, providing a more comprehensive view of hospital use. The linked data set will allow us to determine the patient factors associated with rehospitalization and functional status decline and examine whether higher visit intensity is associated with less rehospitalization, fewer rehospitalization days, longer time to rehospitalization and less functional status decline. Based on 2003 figures, we anticipate 100,000 eligible subjects with HF, 11.000 of whom will be rehospitalized and 20,000 of whom will have a functional status decline. Analysis will use a multi-level modeling approach because of the nested nature of the data. This study is innovative in that it uses national data for all HF patients receiving Medicare home health care and uses county level and agency level data in addition to patient level data which has not been done before in this population. Sub-sample analysis will include the oldest old (>85 years) and minority ethnicity. The clinical application of information from this study, then, is directly relevant to home health care practitioners in designing care practices (how many visits) and for physicians and hospitals who order home health care for HF patients.