Effects of Physician Social Networks on Surgical Quality, Safety, and Costs

描述(由申请人提供)：不同提供者的手术死亡率和每一次手术的费用有很大的差异，这表明有改进的机会。虽然已经推出了各种举措来提高外科护理的安全性、质量和成本效益，但这些努力几乎完全集中在外科医生在手术室和手术后立即进行的活动上。然而，越来越多的人认识到，外科医生、转诊初级保健医生(PCP)和顾问之间的护理协调和沟通是至关重要的。因此，优化手术护理将需要能够衡量和了解参与手术事件的所有医生提供的护理及其相互作用。在此背景下，候选人(约翰·M·霍林斯沃斯博士)试图描述和评估提供外科护理的医生社交网络的有效性。这位候选人是密歇根大学的一名泌尿科医生和卫生服务研究员，他将利用这一提议扩大他的研究议程的科学和临床范围，并促进他成为一名独立的调查员。在支持期间，他将继续在几个学科进行额外的教学，包括网络理论、卫生经济学以及医疗组织和政策方面的研究生和博士生课程。他还将有大量机会接受指导，进行基于项目的学习，包括实践应用先进的统计建模和社交网络分析技术。该研究计划有三个具体目标。具体目标1：绘制提供外科护理的医生社交网络。根据密歇根州蓝十字蓝盾和密歇根州医疗保险计划(2008-2010)的文件，候选人将确定正在接受4种常见住院手术中的1种的受益人。根据手术类型，他将使用一种经过验证的方法来绘制执行这些手术的医院的医生社交网络，在一系列本地和全球网络属性中描述这些社交网络的多个方向。他假设，与服务于农村地区的医生社交网络相比，城市医院的医生数量更多，但他们的平均距离相似。他假设，照顾女性和黑人患者的医生社交网络将分别比为男性和白人患者服务的社交网络更稀疏。具体目标2：评估医生社交网络对手术护理安全和质量的影响。然后，候选人将考察医生的连通性和医院的安全文化/团队合作氛围之间的关联。他还将评估手术质量指标(即手术死亡率、再入院和术后并发症)与手术过程中三个阶段的局部网络属性之间的关系。他假设，外科医生(指PCP)和咨询师倾向于将安全环境聚集在一起的网络。他认为，虽然外科医生的中心地位赋予手术阶段较低的发病率和死亡率，但更大的外科医生与PCP的联系强度会导致较少的并发症和过渡阶段的再入院。具体目标3：检查医生社交网络对手术护理成本的影响。最后，候选人将量化由具有不同水平的医生连接的网络护理的患者的总支出。他将通过比较组成部分支付与全球网络资产来探索具体的节省来源。他假设，不同电视网之间的剧集总支出存在显著差异。他认为，具有凝聚力和密度的网络可以从各种来源获得节省，包括较低的急性后护理费用。拟议研究的完成将向医疗保险和医疗补助服务中心和其他大付款人通报加强医生之间的互动总体上可能对手术护理的安全性、质量和成本产生影响的程度。更广泛地说，这项提案的结果将为研究人员、临床医生领导者和政策制定者提供更多关于不同类型医生之间关系的性质及其对医疗保健提供的重要性的洞察。

DESCRIPTION (provided by applicant): Substantial variation in surgical mortality rates and costs per surgical episode exists across providers, suggesting opportunities for improvement. While a variety of initiatives have been launched to enhance the safety, quality, and cost-efficiency of surgical care, these efforts focus almost exclusively on the surgeon's activities in the operating room and immediately afterward. However, there is growing recognition that coordination of care and communication among the surgeon, the referring primary care physician (PCP), and consultants are crucial. As such, optimizing surgical care will require the ability to measure and understand the care delivered by all physicians involved in the surgical episode and their interactions. In this context, the candidate (Dr. John M. Hollingsworth) seeks to characterize and evaluate the effectiveness of physician social networks that deliver surgical care. The candidate, a urologist and health services researcher at the University of Michigan, will leverage this proposal to broaden the scientific and clinical scope of his research agenda, and to facilitate his development into an independent investigator. During the period of support, he will pursue additional didactic instruction in several disciplines, including graduate- and doctoral-level courses in network theory, health economics, and healthcare organization and policy. He will also have ample opportunities for mentored, project-based learning, including the hands-on application of advanced statistical modeling and the techniques of social network analysis. The research plan has 3 Specific Aims. Specific Aim 1: To map physician social networks that deliver surgical care. With files from Blue Cross Blue Shield of Michigan and Michigan Medicare plans (2008-2010), the candidate will identify beneficiaries undergoing 1 of 4 common inpatient surgical procedures. By surgery type, he will use a validated method to graph physician social networks at hospitals where these procedures are performed, characterizing them in a number of directions across a range of local and global network properties. He hypothesizes that, compared with physician social networks serving rural areas, those at urban hospitals have a larger number of physicians, but their average distances are similar. He posits that physician social networks that care for female and black patients will be sparser than those for male and white patients, respectively. Specific Aim 2: To evaluate the effect of physician social networks on surgical care safety and quality. The candidate will then examine the association between physician connectedness and a hospital's safety culture/teamwork climate. He will also assess for a relationship between measures of surgical quality (i.e., operative mortality, readmissions, and postoperative complications) and local network properties across 3 phases of the surgical episode. He hypothesizes that networks in which the surgeon, referring PCP, and consultant tend to cluster together foster environments of safety. He posits that while surgeon centrality confers lower morbidity and mortality during the operative phase, greater surgeon-PCP tie strength leads to fewer complications and readmissions in the transition phase. Specific Aim 3: To examine the impact of physician social networks on the costs of surgical care. Finally, the candidate will quantify total expenditures for patients cared for by networks with varying levels of physician connectedness. He will explore specific sources of savings by comparing component payments over global network properties. He hypothesizes that significant variation in total episode expenditures exists between networks. He posits that cohesive and dense networks accrue savings from a variety of sources, including lower payments for post-acute care. Completion of the proposed research will inform the Centers for Medicare and Medicaid Services and other large payers on the extent to which strengthening interactions between physicians, in general, might impact on the safety, quality, and costs of surgical care. More broadly, findings from this proposal will provide researchers, clinician leaders, and policymakers with additional insight into the nature of relationships among different types of physicians and their importance for healthcare delivery.