Improving the Quality of Health Systems for the Very Old

描述（由申请人提供）：人们普遍认为，美国的医疗保健系统未能满足美国人口中增长最快的部分——老年人的需求。为了解决当前服务体系质量参差不齐的问题，已经开始了公开报告和按绩效付费的举措。然而，越来越多的人担心，目前的努力可能会损害体弱多病的老年人，因为它把重点放在衡量对年轻人群制定的临床指南的遵守程度上。这些指南提倡的干预措施可长期降低死亡率，但可能产生短期风险。年老体弱者的寿命缩短，这可能意味着他们承担了风险，却没有获益。我们认为，可以利用以病人为中心的价值观，而不是以疾病为基础的指标，作为衡量的概念框架，来有效地衡量老年人保健工作的绩效。作为一名初级研究者，我的长期目标是发展一项研究事业，致力于开发、测试和实施创新的方法来衡量老年人的医疗保健系统质量。这项建议的目标是建立必要的技能和试点数据，成为一个独立的调查员在这个领域。具体的职业发展目标是：(1)发展评估老年人价值或护理需求的专业知识；(2)在使用、整合和分析调查数据和各种行政索赔方面发展先进的专业知识，包括医疗保险索赔和最低数据集；(3)完善开发和应用绩效指标所需的统计分析和建模技能。本提案的研究目标是开发和试点测试，在两个不同的卫生系统，在临终关怀的侵略性，质量措施，反映病人为中心的价值观，为最老的老人医疗保健使用调查和索赔为基础的方法。具体研究目的是：(1)开发一种测量80岁以上老年人或其照顾者对个性化选择支持程度的调查工具；(2)在病人体验（例如连续性）和临床服务（养老院时间和临终关怀）方面，制定以索赔为基础的病人价值护理过程指标；(3)在两个特定的卫生系统中试点测试多模式质量措施，并探讨老年人对以患者为中心的决策的支持与临床服务连续性之间的关系假设。相关性：为老年人提供急症和长期护理花费了数十亿美元。预计这一人口将翻两番，因此必须以最低的费用提供尽可能高质量的保健服务。这一提议的目标是创建质量指标，以监控和提高对老年人的护理质量。

DESCRIPTION (provided by applicant): There is broad agreement that the U.S. health care system fails to meet the needs of the most rapidly growing segment of the U.S. population - the oldest old. Public reporting and pay for performance initiatives are already underway to address the uneven quality of the current delivery system. There is growing concern, however, that current efforts could harm the frail elderly by focusing on measuring adherence to clinical guidelines developed for younger populations. These guidelines promote interventions that lead to long-term mortality benefit but may engender short-term risk. The shortened survival of the very old or frail may mean they accrue the risks without benefit. We believe that valid measures of performance in health care for the oldest old can be created using patient-centered values, rather than disease-based indicators, as the conceptual framework of measurement. As a junior investigator, my long term goal is to develop a research career devoted to developing, testing, and implementing innovative approaches to measuring health care system quality for the oldest old. The goals of this proposal are to build the necessary skills and the pilot data to become an independent investigator in this field. The specific career development aims are: (1) to develop expertise in assessment of values or care needs of the oldest old; (2) to develop advanced expertise in the use, integration, and analysis of survey data and a diverse group of administrative claims including Medicare claims and the Minimum Data Set; (3) to refine skills in statistical analysis and modeling needed for the development and application of performance measures. The research goal of this proposal is to develop and pilot test, in two health systems that differ in aggressiveness of end-of-life care, quality measures that reflect patient-centered values in health care for the oldest old using survey and claims-based methods. The specific research aims are: (1) to develop a survey instrument that measures support for individualized choices for people older than 80 years of age or their caregivers; (2) to develop claims-based indicators of patient-valued processes of care in terms of patient experience (ex. continuity) and clinical services (nursing home time and end-of-life care); and (3) to pilot test the multi-modal quality measures in two specific health system and explore hypotheses about the relationships between support for patient-centered decisions and continuity with clinical services among the very old. Relevance: Billions of dollars are spent on providing acute and long-term care to the very old. The projected quadrupling of this population creates a public health imperative to provide the highest quality care possible at the lowest cost. The goal of this proposal is to create the measures of quality that are needed to monitor and improve the quality of care for the very old.