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，医疗费用高。为了降低再入院率，现已公开报告了心力衰竭的风险标准化医院再入院率，医疗改革建议包括对高再入院率的医院进行处罚。然而，尽管这种强烈的公众兴趣，再入院现象知之甚少，风险标准化再入院率在医院之间差异很大。由于医院、转院和出院后护理质量对再入院风险起重要作用；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、区域和国家层面的医疗保健系统，从而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，为假设检验和未来的干预措施获取数据，并扩大我的指导关系，包括老年和过渡护理专家。具体的职业发展目标是：(1)建立老年病学和老龄化相关知识的基础；(2)运用多种技术发展多领域的质量评估专业知识；(3)获取使用和分析医疗保险索赔数据的经验，以及整合和合并各种大型数据集的经验；(4)发展组织行为学、人体工程学、系统分析和其他技术方面的高级专业知识，以建立安全和以患者为中心的医疗保健系统。我将通过课程作业、指导和研究活动的结合来实现这一目标。本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改变的医疗保健提供因素。具体的研究目的是：(1)比较在全国再入院率前、中、后10%的医院住院的老年心力衰竭患者的临床、过渡期和出院后护理；(2)描述这些医院住院患者再入院的病因和可预防性；(3)确定因医院转诊地区特征导致的心力衰竭风险标准化再入院率的变化比例；(4)确定与老年心力衰竭患者再入院率相关的区域特征。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. Krumholz， E. Bradley），以及多因素老年疾病方面的专家（M. Tinetti）。相关性：老年患者在出院后再入院的风险高得不成比例，特别容易受到不充分的医疗保健系统的影响。本研究旨在确定临床医生、医院和医疗环境对再入院率有影响的领域，以便制定有针对性的、高影响的干预措施，以降低老年患者从医院到家庭的转变后的发病率。

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.