The Impact of Public Reporting on Outcomes and Case Selection for PCI

描述（由申请人提供）：我的职业目标是成为一名独立的护理质量和心血管疾病研究者。为此，我很幸运地从医学院开始就与众多的研究导师一起工作，并希望通过以患者为导向的研究职业发展奖继续这样做。在医学院和住院医师期间，我在杜克临床研究所完成了原始研究和正式的研究培训；最近，我在布里格姆妇女医院（BWH）担任心血管医学临床研究员，在哈佛大学公共卫生学院（HSPH）完成了临床有效性公共卫生硕士学位，现在在布里格姆妇女医院心血管医学部以及HSPH卫生政策与管理系担任研究员。我广泛的研究兴趣是了解我们在全国范围内看到的心血管疾病护理质量和结果差异很大的因素，以及基于政策的质量改进工作对临床质量和患者结果的影响。公共报道是一个特别感兴趣的领域；决策者将公开报告视为提高透明度和推动医疗改善的潜在有力工具。最近通过的《责任医疗法案》（accountability Care Act）在一定程度上推动了对成本和质量的日益重视，人们普遍认为，公开报告的努力将继续扩大，因此这是我特别感兴趣的一个领域。环境：我提出的职业发展计划将在三种情况下发生。首先是HSPH；这个项目需要的一项具体的新技能是定性研究，包括访谈和调查。这是卫生服务研究的一项关键技能，我计划在HSPH参加额外的课程，并寻求在这些领域具有专业知识的同事和教师的具体指导。第二个设置是HSPH的卫生政策和管理系。我的主要导师杰哈博士和共同导师爱泼斯坦博士，都在这个部门担任主要教员职务，他们都是全国公认的衡量护理质量和护理差异的领导者；他们都有丰富的导师经验，并致力于通过指导、建议和研究合作来帮助我实现我的职业目标。第三个地点是BWH的心血管医学部，也是我的共同导师Resnic博士的主要预约地点。Resnic博士曾与马萨诸塞州公共卫生部门密切合作，共同完成目前的公共报告工作，因此对这一主题有着重要的了解。参与该司的活动将使我不仅能够通过一系列临床会议和研究会议了解心血管疾病治疗方面的显著进展，而且还将确保我继续发展可能导致未来富有成效的合作的关系。研究：虽然关注护理过程的公开报告被广泛接受，但关注患者结果的报告很少。经皮冠状动脉介入治疗（PCI）是为数不多的在医院层面公开报道其结果的手术之一；纽约州（NY）和马萨诸塞州（MA）都在全州范围内建立了这一手术的死亡率报告制度。公开报告仍然存在争议：支持者认为这会改善患者的预后，而批评者则认为这可能会导致医生避免为他们认为预后不良的高风险患者提供手术，包括高风险患者和少数族裔患者。然而，缺乏经验数据。据我们所知，目前还没有研究调查公开报告与非公开报告州PCI死亡率的趋势，也只有有限的调查公开报告对获得护理的影响。我们建议使用医疗保险数据来评估公开报告对纽约州和马萨诸塞州接受PCI患者的结果和病例选择的影响。我们也建议调查导管实验室的主管，以确定公开报告是否导致他们采取质量改进活动。我们的具体目的是：确定与对照州相比，纽约州和马萨诸塞州PCI的公开报告是否与PCI死亡率的降低有关；确定纽约州和马萨诸塞州的高风险急性心肌梗死患者在采用公开报告后是否比对照组更少接受PCI治疗；并评估有公开报告的州的心导管实验室主任是否报告采取了具体的质量改进措施。我们相信，这项工作有可能改变当前的思维和政策。绝大多数州尚未采用PCI的结果报告系统。如果我们证明，公开报告导致死亡率下降，而没有减少高风险患者的就诊机会，我们的工作将促进将公开报告作为一种质量改进工具的使用。如果我们没有显示出对死亡率的影响，或对获取的有害影响，我们可能会促使对哪些地方最好采用公开报告进行更谨慎的评估，和/或采取保障重症和少数患者获取的政策。最后，如果我们发现导管实验室正在着手进行重大的质量改进活动，以响应公开报告，我们将为考虑在其州或社区采用公开报告的领导人提供重要支持。

DESCRIPTION (provided by applicant): My career goal is to be an independent researcher in quality of care and cardiovascular disease. To this end, I have been lucky to work with tremendous research mentors since medical school, and hope to continue doing so via the Patient-Oriented Research Career Development Award. I completed original research as well as formal research training at the Duke Clinical Research Institute during medical school and residency; most recently, I have served as a clinical fellow in cardiovascular medicine at Brigham and Women's Hospital (BWH), completed my Masters in Public Health in the concentration of Clinical Effectiveness at the Harvard School of Public Health (HSPH), and now serve as a research fellow in the Division of Cardiovascular Medicine at BWH as well as the Department of Health Policy and Management at HSPH. My broad research interests are in understanding the factors that underlie the wide variation in quality and outcomes of care for cardiovascular disease that we see across the country, and the impact of policy-based quality improvement efforts on clinical quality and patient outcomes. Public reporting is one particular area of interest; public reporting has been seen by policy makers as a potentially potent tool to improve transparency and drive improvements in care. With the increased emphasis being placed on both costs and quality that has been driven, in part, by the recently passed Accountable Care Act, there is broad consensus that public reporting efforts will continue to expand, and thus this is an area in which I am especially interested. Environment: My proposed career development program would occur in three settings. The first is HSPH; one specific new skill that this project would require is qualitative research, including interviews and surveys. This is a critical skill for health services research, and I plan to take additional courses at HSPH and seek specific mentorship from colleagues and faculty who have expertise in these areas. The second setting is the Department of Health Policy and Management at HSPH. My primary mentor, Dr. Jha, and co-mentor, Dr. Epstein, both have their primary faculty appointments in this department, and both are nationally-recognized leaders in measuring quality of care and disparities in care; they both have significant experience as mentors and are dedicated to helping me achieve my career goals through mentoring, advising, and research collaboration. The third setting, the Division of Cardiovascular Medicine at BWH, is where my co-mentor Dr. Resnic has his primary appointment. Dr. Resnic has worked closely with the Massachusetts Department of Public Health on their current public reporting efforts, and thus has significant knowledge of this topic. Involvement with Division activities will allow me to keep current not only on salient advances in the treatment of cardiovascular disease via a host of clinical conferences and research conferences, but would also ensure that I continue to develop relationships that could lead to fruitful collaborations in the future. Research: While public reporting focusing on processes of care is widely accepted, reports focusing on patient outcomes are rare. One of the few procedures for which outcomes are publicly reported at the hospital level is percutaneous coronary intervention (PCI); both New York State (NY) and Massachusetts (MA) have instituted statewide reporting of mortality rates for this procedure. Public reporting remains controversial: proponents believe it leads to improvement in patient outcomes, while critics argue that it may lead physicians to avoid offering procedures to patients whom they perceive to be at high risk for poor outcomes, including high-risk patients and racial and ethnic minorities. However, empirical data is lacking. There have been no studies, to our knowledge, examining trends in PCI mortality in public reporting versus non-public reporting states, and only limited investigation of the impact of public reporting on access to care. We propose to use Medicare data to assess the impact of public reporting on outcomes and case selection for patients undergoing PCI in NY and MA. We also propose to survey directors of catheterization laboratories to determine whether public reporting led them to adopt quality improvement activities. Our specific aims are: to determine whether public reporting for PCI was associated with reductions in mortality for PCI in NY and MA compared to control states; to determine whether high risk patients with acute myocardial infarction had less access to PCI after adoption of public reporting in NY and MA compared to control states; and to assess whether directors of cardiac catheterization laboratories in states with public reporting report the adoption of specific quality improvement efforts. We believe that this work has the potential to shift current thinking and policy. The large majority of states have not adopted outcome reporting systems for PCI. If we demonstrate that public reporting led to decreases in mortality with no reduction in access for high-risk patients, our work will promote the use of public reporting as a quality improvement tool. If we show no impact on mortality, or a deleterious impact on access, we will likely catalyze a more prudent assessment of where public reporting is best employed, and/or adoption of policies that safeguard access for severely ill and minority patients. Finally, if we find that catheterization laboratories are embarking on significant quality improvement activities in response to public reporting, we will give important support to leaders contemplating the adoption of public reporting in their states or communities.