Understanding Dual Use and Other Potential Determinants of Heart Failure Outcomes

了解双重用途和心力衰竭结果的其他潜在决定因素

• 批准号: 8796632
• 负责人: Robert Neal Axon
• 金额: --
• 依托单位: RALPH H JOHNSON VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-12-01 至 2017-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8796632
• 关键词: Accident and Emergency department; Address; Admission activity; Affect; Age; Ambulatory Care; American; American Hospital Association; Applications Grants; Area; Caring; Case Mixes; Cessation of life; Chronic; Chronic Disease; Clinical; Complex; Congestive Heart Failure; Data; Data Analyses; Data Quality; Decision Making; Disease Management; Enrollment; Ethnic Origin; Evaluation; Family member; Focus Groups; Future; Goals; Health; Health Personnel; Health Services Accessibility; Health care facility; Healthcare; Healthcare Systems; Heart failure; Hospitalization; Hospitals; Human Resources; Intervention; Interview; Knowledge; Lead; Learning; Maps; Measures; Medical; Medicare; Methods; Minority; Outcome; Patients; Perception; Population; Preparation; Procedures; Provider; Quality of Care; Research; Research Project Grants; Risk; Rural; South Carolina; Specialist; Structure; System; Systems Development; Testing; Veterans; Visit; cohort; cost; design; follow-up; health administration; health care service utilization; health record; hospital readmission; human old age (65+); improved; mortality; novel; preference; programs; residence; response; statistics; theories; trend

DESCRIPTION (provided by applicant): Anticipated Impacts on Veterans Health Care: By examining the impact of dual health care system use (dual use) and other factors among Veterans with heart failure (HF), the VA will better understand determinants of increased healthcare utilization and poor patient outcomes in this population. This study will lead directly to the development of systems-level interventions to improve care quality for Veterans with HF, while focusing on priority VA research areas of access to care and chronic disease management in an operationally relevant manner. Background: HF is a serious health condition currently affecting 5.8 million Americans and is associated with high 30-day (10.4%) mortality after hospitalization. HF causes 1.1 million hospitalizations and 3.4 million ambulatory care visits each year at an estimated cost of $39.2 billion. Among Veterans, it is the most frequent cause for hospital admission and one of the most frequent causes of unplanned hospital readmission. Dual use occurs frequently in Veterans when those enrolled for VA care also receive care from non-VA providers or facilities. Evidence suggests that dual use is associated with increased healthcare utilization, costs, and worse health outcomes, including increased risk of death. Veterans receiving care at non-VA facilities risk potentially inefficient information exchange, duplicated medical tests and procedures, delays in care, and barriers to follow up. However, very little is known regarding reasons for dual use, predictors of dual use, and impact of dual use on important clinical endpoints in Veterans with HF. Objectives: Study objectives are to 1) understand why Veterans with HF use non-VA facilities for care; 2) identify patient, provider and systems level predictors of dual use in Veterans with HF; and 3) design and evaluate potential interventions focused on addressing dual use and improving HF outcomes. Specific Aim 1: To characterize perceptions regarding access to VA and non-VA care, dual use, and HF care quality among Veterans with HF and VA/non-VA healthcare providers. Specific Aim 2: To determine patient-level and provider/systems-level factors associated with differential health-services utilization and outcomes among Veterans treated for HF. Hypothesis 1: Among Veterans with HF, patient-level factors including dual use, older age, minority ethnicity, rural residence, and multimorbidity will be significantly associated with higher rates of 30-day all-cause hospital readmission and 30-day all-cause mortality after adjusting for relevant covariates. Hypothesis 2: Among Veterans with HF, provider/systems-level factors including higher baseline HF readmission rates, higher measures of HF care quality, worse measures of discharge preparation, smaller facility size, lower number of HF specialists, and more complex hospital case-mix will be associated with higher rates of 30-day all-cause hospital readmission and 30-day all-cause mortality after adjusting for relevant covariates. Specific Aim 3: To integrate data from secondary data analyses and key stakeholder interviews to facilitate the design and formative evaluation of interventions focused on reducing unplanned and potentially preventable HF hospitalizations among Veterans. Methods: For Aim 1, we will conduct semi-structured interviews using grounded theory to explore perceptions of access to care, dual use, and HF care quality. For Aim 2, we will merge VA/Medicare data for Veterans with HF in SC with comprehensive ED/hospitalization data from the SC Office of Research and Statistics as well as hospital data from American Hospital Association and quality data from CMS. For Aim 3, data from Aims 1 and 2 will be synthesized and used to design novel programs to reduce avoidable HF hospitalizations and readmissions. Finally, in response to calls for formative evaluation in intervention planning, we will conduct focus group sessions with patients and providers to assess the feasibility and acceptability of planned interventions in preparation for future grant proposals.

描述（由申请人提供）： 对退伍军人卫生保健的预期影响：通过检查双重医疗保健系统的使用（双重使用）和心力衰竭的退伍军人（HF）的其他因素，VA将更好地了解该人群中医疗保健利用率增加和患者不良结果的决定因素。这项研究将直接导致系统级干预的发展 提高HF的退伍军人的护理质量，同时以操作相关的方式专注于VA研究领域。背景：HF目前是一种严重的健康状况，目前影响580万美国人，与住院后30天（10.4％）的高死亡率有关。 HF每年造成110万个住院和340万个门诊护理访问，估计成本为392亿美元。在退伍军人中，这是入院的最常见原因，也是最常见的医院再入院原因之一。当参加VA护理的人还从非VA提供者或设施获得护理时，双重使用经常发生在退伍军人中。有证据表明，双重使用与增加医疗保健利用，成本和恶化的健康结果有关，包括死亡风险增加。在非VA设施接受护理的退伍军人可能会冒可能会效率低下的信息交换，重复的医疗测试和程序，护理延迟以及跟进的障碍。但是，关于双重使用的原因，双重使用的预测因素以及双重使用对HF的重要临床终点的影响很少，知之甚少。目标：研究目标是1）理解为什么拥有HF的退伍军人使用非VA设施进行护理； 2）确定HF退伍军人的患者，提供者和系统级别的预测因素； 3）设计和评估潜在的干预措施，重点是解决双重使用和改善HF结果。具体目的1：表征有关HF和VA/NON-VA医疗保健提供者的退伍军人中有关访问VA和非VA护理，双重使用和HF护理质量的看法。特定目的2：确定患者级别和提供商/系统级别的因素，与接受HF治疗的退伍军人之间的差异化健康服务利用和结果相关。假设1：在患有HF的退伍军人中，患者级别的因素，包括双重使用，年龄较大，少数民族，农村居住和多种多样，将 在调整相关协变量后，与30天全因医院再入院和30天全因死亡率的率显着相关。假设2：在具有HF的退伍军人中，提供商/系统级别的因素，包括较高的基线HF再入院率，更高的HF护理质量衡量标准，较差的出院准备度量，较小的设施量，较小的设施尺寸，较低的HF专家数量以及更复杂的医院病例将与30天的所有因素全因医院再入院和30天的较高率相关。特定目的3：整合次要数据分析和关键利益相关者访谈的数据，以促进对重点减少退伍军人之间计划外的HF住院的设计和形成性评估。方法：对于AIM 1，我们将使用扎根理论进行半结构化访谈，以探索对获得护理，双重使用和HF护理质量的感知。对于AIM 2，我们将与SC中的HF合并为退伍军人的VA/Medicare数据与SC研究与统计办公室的全面ED/住院数据以及美国医院协会的医院数据以及CMS的质量数据。对于AIM 3，将合成AIM 1和2的数据，并用于设计新颖的计划，以减少可避免的HF住院和再入院。最后，为了回应在干预计划中进行形成性评估的呼吁，我们将与患者和提供者进行焦点小组会议，以评估计划干预措施的可行性和可接受性，以准备未来的赠款建议。