STUDY OF HOSPITALS STAFFING ATTENDING PHYSICIAN ROLE FOR PATIENTS AT END OF LIFE

为了应对不断变化的政策和市场条件，医院必须决定如何配备主治医生，因为这个人在协调患者护理方面发挥着关键作用，包括及时和安全地出院，避免再次入院。2013年，医院现在因30天再入院率高于预期而受到惩罚。在本申请中，我们建议研究患有严重功能障碍的NH居民中的3种典型疾病轨迹，以了解医院如何选择主治医生角色：1）具有高级认知的痴呆症; 2）CHF引起的终末器官功能障碍; 3）患有肺炎的住院NH居民，伴有预先存在的严重功能障碍。痴呆症是一种具有长期严重功能障碍的典型疾病，其中医疗决策必须权衡生活质量与数量。后两个队列挑战医疗保健提供者协调医疗保健设置，以避免再入院，并与患者和/或家庭就护理目标作出决定。使用MDS和医疗保险索赔数据从2000年到2014年，我们建议描述医院的决定，以工作人员的主治医生的作用（目标I），并检查这些决定对临床结果和健康护理利用的影响经验的体弱老人，NH居民（目标II）。截至2013年，医院因急性心肌梗死、充血性心力衰竭和肺炎患者的30天再住院率高于预期而面临处罚。我们的第三个目标是估计这一新政策的预期和潜在的非预期后果。最后的第四个目标建议进行8个案例研究，以了解30天再入院率较高和较低的医院如何组织医生服务，并与NH医务人员协调护理，为这3个拟议的体弱、老年和高血压患者队列中的每一个提供高质量的护理。 人士拟议的研究将提供政策相关的信息，以检查观察到的特征和医院人员配置的显着变化，主治医生的作用，以及评估ACA处罚的影响，医院30天的再入院率较高。

In response to changing policies and market conditions, hospitals must make decisions about how to staff the role of the attending physician since this individual plays a pivotal role in coordinating patient care, including timely and safe discharges that avoid hospital readmission. In 2013, hospitals are now penalized for higher than expected 30-day readmissions rates. In this application, we propose to study 3 paradigmatic illness trajectories among NH residents with severe functional impairment in order to understand how hospitals choose to staff the attending physician role: 1) dementia with advance cognitive; 2) end organ dysfunction from CHF; and 3) hospitalized NH residents with pneumonia with pre-existing severe functional impairment. Dementia is a paradigmatic illness with prolonged severe functional impairment where medical treatment decisions must weigh quantity vs. quality of life. The latter two cohorts challenge health care providers to coordinate care across health care settings to avoid hospital readmissions and to make decisions with the patient and/or family regarding the goals of care. Using the MDS and Medicare claims data from 2000 to 2014, we propose to characterize hospitals' decisions to staff the role of the attending physician (Aim I) and examine the impact of those decisions on clinical outcome and health care utilization experienced by frail elderly, NH residents (Aim II). As of 2013, hospitals are faced with penalties for having a higher than expected 30 day re-hospitalization rates for patients with acute myocardial infarction, congestive heart failure, and pneumonia. Our third aim is to estimate the intended and potential unintended consequence of this new policy. A final fourth aim proposes to conduct 8 case studies to understand how hospitals with higher and lower rates of 30-day readmission organize physician services and coordinate care with the NH medical staff to provide high quality of care for each of these 3 proposed cohorts of frail, older persons. The proposed research will provide policy relevant information to examine observed dramatic changes in characteristics and hospital staffing the role of the attending physician as well as evaluate the impact of ACA penalties for hospitals with higher rates of 30 days hospital readmissions.