The Impact of Quality Metrics on Outcomes Among Elderly Heart Failure Patients

质量指标对老年心力衰竭患者预后的影响

• 批准号: 10207751
• 负责人: Lauren Gray Gilstrap
• 金额: $ 13.79万
• 依托单位: DARTMOUTH-HITCHCOCK CLINIC
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-08-25 至 2023-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10207751
• 关键词: Acute; Acute Renal Failure with Renal Papillary Necrosis; Admission activity; Adrenergic beta-Antagonists; Age; Angiotensin II Receptor; Angiotensin-Converting Enzyme Inhibitors; Attention; Cardiology; Caring; Characteristics; Clinical; Clinical Management; Clinical Trials; Clinical assessments; Creatinine; Data; Dimensions; Drug usage; EFRAC; Effectiveness; Elderly; Enrollment; Evaluation; Foundations; Future; Guidelines; Heart failure; Heterogeneity; Hospitalization; Hospitals; Hypotension; Incentives; Incidence; Interview; Knowledge; Link; Measurement; Measures; Medicare; Medicare Part A; Methods; Modeling; Outcome; Patient Care; Patient Preferences; Patients; Performance; Pharmaceutical Preparations; Play; Population; Population Heterogeneity; Potassium; Provider; Quality of Care; Quality of life; Randomized Controlled Trials; Recording of previous events; Registries; Risk; Role; Structure; Symptoms; System; Variant; Work; base; beneficiary; care providers; clinical care; comorbidity; comparative effectiveness; data registry; economic implication; efficacy evaluation; frailty; high risk; hospital readmission; improved; interest; medication safety; mortality; multiple chronic conditions; next generation; older patient; patient population; patient response; payment; personalized approach; preference; programs; randomized trial; research clinical testing; side effect

Project Summary/Abstract 1 Quality of care has become a significant component of provider evaluation and reimbursement. As alternative payment 2 models gain popularity and the new Merit-Based Incentive Payment (MIPS) program rolls out, how quality is defined and 3 measured will become increasingly important for patients, providers and payers. In the field of cardiology, most quality 4 metrics are based on findings from large, randomized trials. While robust, randomized trials can be limited in their 5 generalizability, owing to narrowly defined enrollment criteria and the underrepresentation of certain patient populations. 6 This can result in a mismatch between the population in which a therapy has been proven effective and the population in 7 which quality metrics require it use. This, in turn, can create a system of quality measurement that inadvertently incentives 8 non-evidenced based practice or unfairly penalizing certain providers. An example is the use of neurohormonal therapy in 9 elderly patients with heart failure and reduced ejection fraction (HFrEF). Neurohormonal therapies, which include 10 angiotensin converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARB) and beta-blockers, are the 11 cornerstone of HFrEF therapy and their use now defines quality in HFrEF care. While neurohormonal therapies are 12 undoubtedly beneficial in the vast majority of HFrEF patients, elderly patients ≥75 years old were underrepresented in the 13 landmark studies that evaluated the efficacy and safety of these drugs. Since neurohormonal therapies carry a non-trivial 14 risk of side effects, it is possible that the short term risks of therapy outweigh the longer term benefits in certain elderly 15 patients. At present however, neither clinical guidelines nor quality metrics account for this known heterogeneity among 16 elderly HFrEF beneficiaries. To better understand the impact of neurohormonal therapy on elderly HFrEF patients, 17 determine how best to use neurohormonal therapy in elderly HFrEF patients and more effectively measure quality of care 18 among elderly HFrEF patients, a 3-part analysis using administrative, registry and qualitative data is proposed. The 19 project aims to (1) use Medicare data to determine whether and how the clinical benefits of neurohormonal therapy vary 20 by age; (2) to use the national registry data linked with Medicare data to determine characteristics that predict likelihood 21 to benefit from neurohormonal therapy among elderly HFrEF patients and simulate the effectiveness of a targeted 22 approach to therapy using the identified characteristics; and (3) to use semi-structured patient interviews to determine the 23 aspects of care that define “high quality care” for elderly HFrEF patients. This work has the potential to both improve the 24 quantity of care and the quality of life for elderly HFrEF patients as well as improve our current method of quality 25 measurement in heart failure. First, an assessment of existing variation in outcomes with neurohormonal therapy, by age, 26 will define the scope of the issue and the potential for improvement. Secondly, identification of the patient-level 27 characteristics associated with a high likelihood of benefit (or harm) from neurohormonal therapy among elderly HFrEF 28 patients will enable improved clinical care and the refinement of current quality metrics. Finally, a qualitative assessment 29 of elderly HFrEF patient priorities will lay the foundation for future research to develop the next generation of quality 30 metrics that incorporate patient preferences.

项目总结/摘要 1护理质量已成为提供者评估和报销的重要组成部分。作为替代付款 2款车型广受欢迎，新的基于绩效的激励支付（MIPS）计划推出，如何定义质量， 3衡量将成为越来越重要的患者，提供者和付款人。在心脏病学领域， 4个指标基于大型随机试验的结果。虽然强有力，随机试验可能是有限的， 5普遍性，由于狭窄定义的入组标准和某些患者人群的代表性不足。 6这可能导致治疗已被证明有效的人群与治疗有效的人群之间的不匹配。 7、哪些质量指标需要使用。这反过来又会建立一个质量衡量体系， 8.无证据的做法或不公平地惩罚某些提供者。一个例子是使用神经激素治疗， 9例心力衰竭和射血分数降低（HFrEF）的老年患者。神经激素疗法，包括 10血管紧张素转换酶抑制剂（ACEi）/血管紧张素II受体阻滞剂（ARB）和β-受体阻滞剂，是 HFrEF治疗的11个基石及其使用现在定义了HFrEF护理的质量。虽然神经激素疗法 12在绝大多数HFrEF患者中无疑是有益的，≥75岁的老年患者在 13项具有里程碑意义的研究评估了这些药物的疗效和安全性。由于神经激素疗法具有重要的 14副作用的风险，在某些老年人中，治疗的短期风险可能超过长期益处。 15个病人然而，目前，临床指南和质量指标都没有考虑到这种已知的异质性， 16名长者家庭资助计划受惠人。为了更好地了解神经激素治疗对老年HFrEF患者的影响， 17确定如何在老年HFrEF患者中最好地使用神经激素治疗，并更有效地衡量护理质量 18在老年HFrEF患者中，提出了使用管理、登记和定性数据的3部分分析。的 19项目旨在（1）使用医疗保险数据来确定神经激素治疗的临床益处是否以及如何变化 20岁;（2）使用与Medicare数据相关的国家登记数据来确定预测可能性的特征 21例老年HFrEF患者受益于神经激素治疗，并模拟靶向治疗的有效性。 （3）使用半结构化的患者访谈来确定 定义老年HFrEF患者“高质量护理”的23个护理方面。这项工作有潜力既改善 24护理质量和生活质量的老年HFrEF患者以及改善我们目前的方法质量 25心力衰竭的测量。首先，按年龄评估神经激素治疗结果的现有变化， 26将界定问题的范围和改进的潜力。第二，患者层面的识别 与老年HFrEF患者神经激素治疗获益（或损害）可能性高相关的27个特征 28名患者将能够改善临床护理和完善当前的质量指标。最后，定性评估 老年HFrEF患者优先考虑的29项研究将为未来研究开发下一代质量奠定基础 包含患者偏好的30个指标。