Heart Failure Readmissions in Older Adults: A systems Perspective

描述(由申请人提供)：四分之一因心力衰竭入院的老年患者在出院后30天内再次入院，导致老年人发病率增加和医疗费用高昂。为了降低再住院率，现在公开报告了心力衰竭的风险标准化医院再住院率，医疗改革提案包括对再住院率高的医院进行处罚。然而，尽管公众对此兴趣浓厚，但人们对再入院现象知之甚少，风险标准化的再入院率在不同医院之间差异很大。由于医院的质量，过渡期和出院后护理在再入院风险中扮演着重要的角色；我们从系统的角度来处理这个问题。我的长期目标是发展一项研究事业，致力于改善地方、地区和国家层面的医疗体系，以便它们最大限度地提高老年患者的护理质量、患者安全、协调和沟通。这项建议的目标是建立我在这一领域的技能集，获得用于假设检验和未来干预的数据，并扩大我的指导关系，将老年和过渡期护理专家包括在内。具体的职业发展目标是：(1)建立老年和老龄化相关知识的基础；(2)利用各种技术在多个领域发展质量评估方面的专业知识；(3)在使用和分析联邦医疗保险索赔数据以及整合和合并不同的大型数据集方面获得经验；以及(4)发展建立安全和以患者为中心的医疗保健系统所需的组织行为、人类工效学、系统分析和其他技术方面的高级专业知识。我将通过课程作业、指导和研究活动相结合的方式来实现这一点。这项提案的研究目标是更好地了解对老年患者再入院有影响的可修改的医疗保健提供因素。具体的研究目标是：(1)比较全国再住院率前、中和后10%的老年心力衰竭患者的临床、过渡期和出院后护理；(2)描述这些医院入院的老年心力衰竭患者的病因和可预防性；(3)确定由于医院转诊地区的特点而导致的心力衰竭风险标准化再住院率的差异比例；以及(4)确定与老年心力衰竭入院患者再住院率相关的地区特征。我的指导团队包括心力衰竭再入院和质量测量方面的专家(H.克鲁姆霍尔茨，E.布拉德利)和多因素老年病专家(M.Tinetti)。相关性：老年患者出院后再入院的风险高得不成比例，而且特别容易受到医疗保健系统不足的影响。这项研究旨在确定临床医生、医院和医疗环境对再住院率有影响的领域，以便开发有针对性的、高影响的干预措施，以减少医院到家庭过渡后老年患者的发病率。 公共卫生相关性：四分之一因心力衰竭(HF)入院的患者在出院30天内再次入院。由于老年患者在住院期间发生不良事件的风险很高，而且仅再次住院一项就花费了医疗保健系统每年超过170亿美元，因此非常希望通过保持患者更健康来避免再次住院。这项研究旨在确定临床医生、医院和更广泛的医疗环境对再入院率的影响，以便开发有针对性的、高影响力的干预措施，帮助老年心力衰竭患者在家而不是回到医院。

DESCRIPTION (provided by applicant): One quarter of older patients admitted for heart failure are readmitted within 30 days of discharge, resulting inincreased morbidity for seniors and high healthcare costs. In an effort to reduce the readmission rate, a risk-standardized hospital readmission rate for heart failure is now publicly reported, and health reform proposals include penalties for hospitals with high readmission rates. Yet despite this intense public interest, the phenomenon of readmission is poorly understood, and risk-standardized readmission rates vary widely among hospitals. Since quality of hospital, transitional and post-discharge care plays an important role in readmission risk; we approach this problem from a systems perspective. My long-term goal is to develop a research career dedicated to improving healthcare systems at the local, regional and national level so that they maximize care quality, patient safety, coordination and communication for older patients. The goals of this proposal are to build my skill set in this area, acquire data for hypothesis testing and future interventions, and to expand my mentoring relationships to encompass geriatric and transitional care experts. The specific career development aims are: (1) to build a foundation of geriatric and aging-related knowledge; (2) to develop expertise in quality assessment in multiple domains using a variety of techniques; (3) to gain experience in the use and analysis of Medicare claims data, and in the integration and merging of a diverse group of large datasets; and (4) to develop advanced expertise in organizational behavior, human ergonomics, systems analysis and other techniques necessary for building safe and patient-centered healthcare systems. I will accomplish this through a combination of coursework, mentorship and research activities. The research goal of this proposal is to develop a better understanding of the modifiable healthcare delivery factors that have an impact on readmissions for geriatric patients. The specific research aims are: (1) to compare clinical, transitional, and post-discharge care for older patients with heart failure admitted to hospitals in the top, middle and bottom ten percent of readmission rates nationally; (2) to describe the etiology and preventability of readmissions in patients admitted to these hospitals; (3) to determine the proportion of variation in risk-standardized readmission rates for heart failure attributable to hospital referral region characteristics; and (4) to identify regional characteristics that are associated with readmission rates for older patients admitted with heart failure. My mentorship team includes experts in heart failure readmissions and quality measurement (H. Krumholz, E. Bradley), and an expert in multi-factorial geriatric conditions (M. Tinetti). Relevance: Older patients have a disproportionately high risk of readmission after hospital discharge and are particularly vulnerable to inadequate healthcare systems. This study is intended to identify the areas in which clinicians, hospitals, and the healthcare environment have influence over readmission rates, in order to develop targeted, high-impact interventions to reduce morbidity in older patients after the hospital-to-home transition. PUBLIC HEALTH RELEVANCE: One quarter of patients admitted for heart failure (HF) are readmitted within 30 days of discharge. Since older patients are at high risk for adverse events during hospitalizations, and since re-hospitalizations alone cost the healthcare system over $17 billion a year, it is highly desirable to avoid readmissions by keeping patients healthier. This study is intended to determine what influence clinicians, hospitals, and the broader healthcare environment have over readmission rates, in order to develop targeted, high-impact interventions to help keep older patients with HF safe at home instead of back in the hospital.