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

公开报告对 PCI 结果和案例选择的影响

• 批准号: 8165932
• 负责人: Karen Ellen Joynt Maddox
• 金额: $ 13.82万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-08-19 至 2016-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8165932
• 关键词: Acute myocardial infarction; Adopted; Adoption; Appointment; Area; Behavior; Cardiac Catheterization Procedures; Cardiogenic Shock; Cardiovascular Diseases; Cardiovascular system; Caring; Catheterization; Clinical; Clinical Research; Clinical effectiveness; Collaborations; Communities; Consensus; Coronary Artery Bypass; Country; Data; Disincentive; Ensure; Environment; Faculty; Future; Geographic Locations; Goals; Health Policy; Health Services Accessibility; Health Services Research; Healthcare Systems; Hospitals; Individual; Institutes; Interview; Investigation; K-Series Research Career Programs; Knowledge; Laboratories; Lead; Literature; Massachusetts; Measures; Medical Residency; Medicare; Medicine; Mentors; Mentorship; Minority; Minority Groups; New York; Operative Surgical Procedures; Outcome; Patient Selection; Patients; Pattern; Performance; Physicians; Policies; Policy Maker; Procedures; Process; Provider; Public Health; Public Health Schools; Qualitative Research; Quality of Care; Reporting; Research; Research Institute; Research Personnel; Research Training; Risk; Shock; Surveys; System; Thinking; Time; Variant; Woman; Work; base; career; career development; clinical care; clinical conference; cost; experience; health care quality; high risk; improved; innovation; interest; medical schools; mortality; patient oriented research; patient population; patient registry; percutaneous coronary intervention; programs; racial and ethnic; response; skills; symposium; tool; trend

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.

描述（由申请人提供）：我的职业目标是成为护理质量和心血管疾病的独立研究人员。 为此，我很幸运从医学院开始就与众多研究导师合作，并希望通过以患者为导向的研究职业发展奖继续这样做。我在医学院和住院医师期间在杜克临床研究所完成了原创性研究以及正式的研究培训;最近，我在布里格姆妇女医院（BWH）担任心血管医学的临床研究员，在哈佛公共卫生学院（HSPH）完成了临床有效性专业的公共卫生硕士学位，现在担任BWH心血管医学部以及HSPH卫生政策和管理部的研究员。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的广泛差异的基础因素，以及基于政策的质量改进工作对临床质量和患者结局的影响。公共报告是一个特别令人感兴趣的领域;公共报告被政策制定者视为提高透明度和推动护理改进的潜在有力工具。随着越来越多的重点放在成本和质量上，这在一定程度上是由最近通过的《责任关怀法》推动的，人们普遍认为，公开报道的努力将继续扩大，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个环境中进行。第一个是HSPH;这个项目需要的一个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。第二个设置是卫生政策和管理部在HSPH。我的主要导师Jha博士和共同导师Epstein博士都在该部门担任主要教职，并且都是衡量护理质量和护理差异方面的全国公认的领导者;他们都拥有丰富的经验作为导师，并致力于通过指导、建议和研究合作帮助我实现职业目标。第三个设置，BWH心血管医学部，是我的共同导师Resnic博士的主要任命。Resnic博士与马萨诸塞州公共卫生部就其当前的公共报告工作密切合作，因此对这一主题有着丰富的知识。 参与部门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的显著进展，而且还将确保我继续发展关系，从而在未来实现富有成效的合作。 研究：虽然关注护理过程的公共报告被广泛接受，但关注患者结果的报告很少。经皮冠状动脉介入治疗（PCI）是在医院层面公开报告结局的少数手术之一;纽约州（NY）和马萨诸塞州（MA）都制定了全州范围内该手术死亡率的报告。公开报告仍然存在争议：支持者认为它会改善患者的预后，而批评者认为它可能会导致医生避免向他们认为预后不良的高风险患者提供手术，包括高风险患者和种族和少数民族。然而，缺乏经验数据。据我们所知，目前还没有研究，检查PCI死亡率的趋势，在公共报告与非公共报告的国家，只有有限的调查的影响，公共报告获得护理。我们建议使用医疗保险数据来评估公共报告对纽约和马萨诸塞州接受PCI患者的结局和病例选择的影响。我们还建议调查导管实验室主任，以确定是否公开报道导致他们采取质量改进活动。我们的具体目标是：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死亡率降低相关;确定与对照州相比，纽约州和马萨诸塞州采用公开报告后，急性心肌梗死高危患者接受PCI的机会是否减少;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。我们认为，这项工作有可能改变目前的思维和政策。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，而不减少高风险患者的访问，我们的工作将促进使用公开报告作为质量改进工具。如果我们显示对死亡率没有影响，或者对获取造成有害影响，我们可能会促进对最佳使用公共报告的地方进行更谨慎的评估，和/或采取保障重症患者和少数民族患者获取的政策。最后，如果我们发现导管插入术实验室正在开展重大的质量改进活动，以应对公开报告，我们将给予重要的支持，领导人考虑通过公开报告在他们的国家或社区。