Healthcare Fragmentation and Cardiovascular Outcomes

医疗保健碎片化和心血管结果

• 批准号: 9921482
• 负责人: Lisa M Kern
• 金额: $ 78.24万
• 依托单位: WEILL MEDICAL COLL OF CORNELL UNIV
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-05-15 至 2022-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9921482
• 关键词: Affect; Ancillary Study; Cardiovascular system; Caring; Cessation of life; Characteristics; Chronic; Chronic Disease; Client satisfaction; Clinical; Communication; Coronary Arteriosclerosis; Data; Drug Interactions; Emergency department visit; Funding; Future; Goals; Health; Health Expenditures; Health Personnel; Healthcare; Healthcare Systems; Hospitalization; Income; Individual; Intervention; Lead; Link; Measures; Medicare; Medicare claim; Methodology; Myocardial Infarction; Outcome; Outpatients; Participant; Patient Care; Patient Self-Report; Patient-Focused Outcomes; Patients; Patterns of Care; Physicians; Population; Primary Care Physician; Primary Health Care; Procedures; Prospective cohort study; Provider; Psychosocial Factor; Race; Reasons for Geographic And Racial Differences in Stroke; Recurrence; Research; Risk; Specialist; Stroke; Surveys; Testing; United States National Institutes of Health; Visit; Work; adjudicate; base; beneficiary; cardiovascular disorder epidemiology; care fragmentation; care providers; cohort; comorbidity; density; design; experience; health care delivery; high risk; hospital readmission; improved outcome; indexing; innovation; interest; mortality; multidisciplinary; psychosocial; stroke outcome

Patients with chronic disease often see a multitude of outpatient providers. For example, Medicare beneficiaries with coronary artery disease each see a median of 10 physicians (3 primary care physicians and 7 specialists) in 6 different practices each year. Seeing more than one physician may be clinically appropriate and indeed may be necessary in order to receive recommended care. However, highly fragmented care increases the risk of gaps in communication across providers. Prior studies suggest that more fragmented care can lead to suboptimal care, with more adverse drug interactions, more testing, more procedures, and lower patient satisfaction, compared to less fragmented care. However, which patients are at greatest risk for healthcare fragmentation and how fragmentation affects patient outcomes are not known. In addition, individuals' experiences of fragmented care are poorly understood, even though understanding individuals' experiences is critical for identifying potential solutions. The overall objective of this proposal is to determine the association between healthcare fragmentation and cardiovascular outcomes, by conducting an ancillary study to the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. REGARDS is a national, NIH-funded prospective cohort study, which began in 2003 and is ongoing. It includes detailed data on participants' demographic characteristics, co- morbidities, psychosocial variables, and adjudicated myocardial infarction and stroke outcomes. The proposed project will include a subset of 7,120 participants for whom REGARDS data have been linked to Medicare claims at baseline. Fragmentation will be measured from claims, primarily using the Bice-Boxerman Index, a commonly used measure of fragmentation that captures both “dispersion” (the spread of a patient's care across multiple providers) and “density” (the relative share of visits by each provider). Fragmentation will also be measured through participant surveys, using a measure previously validated in a Medicare population. The specific aims include determining: 1) which participants are at highest risk of having healthcare fragmentation, 2) associations between claims-based fragmentation and outcomes, and 3) associations between self-reported fragmentation and outcomes. The outcomes of interest include myocardial infarction, stroke, death, emergency department visits, hospitalizations, and healthcare expenditures. This study represents an innovative use of a large cohort to understand the problem of healthcare fragmentation. The research team is highly experienced and multidisciplinary, with national experts in cardiovascular epidemiology and healthcare delivery. Results from the proposed study can be used to inform the design of future interventions to decrease fragmentation and improve outcomes.

患有慢性病的患者经常看到许多门诊提供者。例如， 患有冠状动脉疾病的受益人每人平均看10名医生（3名初级保健医生， 7名专家）每年在6个不同的实践中。看一个以上的医生在临床上可能是合适的 并且实际上可能是为了接受推荐的护理所必需的。然而，高度分散的护理 增加了供应商之间沟通差距的风险。先前的研究表明，更分散的护理 可能导致不理想的护理，更多的药物不良相互作用，更多的测试，更多的程序， 患者满意度，与不太分散的护理相比。然而，哪些患者的风险最大 医疗保健碎片化以及碎片化如何影响患者结果尚不清楚。此外，本发明还提供了一种方法， 人们对个人的零散护理经验知之甚少，即使了解个人的 经验对于确定可能的解决办法至关重要。 本提案的总体目标是确定医疗保健碎片化与 心血管结局，通过对地理和种族原因进行辅助研究 卒中差异（REGARDS）研究。REGARDS是一项由NIH资助的全国性前瞻性队列研究， 始于2003年，至今仍在进行中。它包括参与者人口统计特征的详细数据， 发病率、心理社会变量以及判定的心肌梗死和卒中结局。拟议 该项目将包括7，120名参与者的子集，这些参与者的REGARDS数据已与Medicare相关联 基线索赔。碎片化将从索赔中衡量，主要使用Bice-Boxerman指数， 一种常用的碎片化测量方法，它既可以捕获“分散度”（患者护理的分散度 跨多个提供者）和“密度”（每个提供者访问的相对份额）。碎片化也将 通过参与者调查进行衡量，使用之前在医疗保险人群中验证的衡量标准。的 具体目标包括确定：1）哪些参与者处于具有医疗保健碎片化的最高风险， 2)基于索赔的碎片化与结果之间的关联，以及3）自我报告的 碎片化和结果。关注的结局包括心肌梗死、卒中、死亡、急诊 部门访问、住院和医疗保健支出。 这项研究代表了一个创新的使用大型队列，以了解医疗保健的问题， 碎片化该研究团队经验丰富，多学科，与国家专家在 心血管流行病学和医疗保健服务。拟议研究的结果可用于告知 设计未来的干预措施，以减少分散和改善成果。