Identifying effective strategies used by Medicare Accountable Care Organizations to improve outcomes for patients with heart failure: A mixed-methods study

项目总结 超过570万美国成年人患有心力衰竭(HF)，患病率预计还会增加 在接下来的20年里增长46%。心力衰竭护理的总费用每年超过300亿美元。心力衰竭患者在 不良结局的高风险，包括住院、残疾和死亡。一种新的降压干预方法 提高医疗保险受益人的医疗成本和质量是责任医疗的实施 组织(ACO)。ACO由聚集在一起的医生和其他医疗保健实体组成 自愿为患者提供协调的、高质量的护理。如果这导致成本降低，ACO 与联邦医疗保险计划分享节省的资金。ACO同时需要满足以下质量指标 确保成本降低是人口健康改善的结果(而不是否认的结果 为受益人提供的服务)。截至2017年，联邦医疗保险共享储蓄计划(MSSP)是一项大型医疗保险 为ACO的形成提供激励的计划，包括超过900万的医疗保险患者 全国范围内有400多名ACO。初步数据显示，不同的ACO在以下方面的结果存在差异 心衰患者。我们假设，这种差异与组织和交付方面的差异有关 ACOS内部的护理。例如，护理管理的使用或实施可能因ACO而异，从而导致 结果上的差异。 我们的长期目标是确定有效的交付系统干预措施，以改善健康和 心衰患者的转归。这项建议的目标是确定战略和背景因素 这导致一些ACO实现了更好的风险标准化结果，包括：更低的急性住院率 (RSARS)、更少的熟练护理天数(RSSNF)和更低的死亡率(RSRs)。目标1将 检查不同ACO的结果，并确定结果随时间变化的轨迹。每个ACO将 根据风险标准化结果的趋势被分配一个“表型”。然后我们将研究 表型与ACO特征的相关性。在目标2中，我们将对以下人员进行定性访谈 一个取自高性能和低性能表型的ACO样本，目的是完善我们的理解 有哪些因素和战略使一些反兴奋剂机构能够取得更好的成果。对于目标3，我们将进行 调查所有剩余的MSSP ACO(未在目标2中抽样的那些)，以检查已确定的 使用多项回归的策略和结果。这项工作的结果将通知卫生系统 领导者和政策制定者在ACOS内实施护理管理战略并考虑变革 更广泛地说是MSSP。这些活动对国家心脏、肺脏和血液高度敏感 研究所的战略目标和目标，特别是目标6，旨在“优化翻译， 临床和实施研究，以改善健康和减少疾病。

PROJECT SUMMARY More than 5.7 million American adults experience heart failure (HF), and prevalence is expected to increase by 46% in the next two decades. Total costs of HF care exceed $30 billion annually. Patients with HF are at high risk for poor outcomes, including hospitalization, disability, and death. A novel intervention for lowering costs and improving quality of care for Medicare beneficiaries is the implementation of Accountable Care Organizations (ACOs). ACOs consist of groups of doctors and other health care entities that come together voluntarily to provide their patients with coordinated, high-quality care. If this results in lower costs, the ACO shares the savings with the Medicare program. ACOs are simultaneously required to meet quality metrics to ensure that cost reductions are the result of improvements in population health (and not the result of denying services to beneficiaries). As of 2017, the Medicare Shared Savings Program (MSSP), a large Medicare program that provides incentives for ACO formation, included more than 9 million Medicare patients across more than 400 ACOs nationwide. Preliminary data suggests there is variation across ACOs in outcomes for patients with HF. We hypothesize that this variation is related to differences in the organization and delivery of care within ACOs. For example, use or implementation of care management may vary across ACOs, leading to differences in outcomes. Our long-term goal is to identify effective delivery-system interventions that improve the health and outcomes of patients with HF. The objective of this proposal is to identify the strategies and contextual factors that lead some ACOs to achieve better risk-standardized outcomes including: lower acute admission rates (RSAARs), fewer days in skilled nursing care (RSSNFs), and lower mortality rates (RSMRs). Aim 1 will examine outcomes across ACOs and identify patterns in the trajectories of outcomes over time. Each ACO will be assigned a “phenotype” based on trends in risk-standardized outcomes. We will then examine the association between phenotypes with ACO characteristics. In Aim 2, we will conduct qualitative interviews with a sample of ACOs taken from high- and low- performing phenotypes with the goal of refining our understanding of the factors and strategies that allow some ACOs to achieve better outcomes. For Aim 3, we will conduct a survey of all remaining MSSP ACOs (those not sampled in Aim 2) to examine associations between identified strategies and outcomes using multinomial regression. The results of this work will inform health system leaders and policymakers as they implement care management strategies within ACOs and consider changes to the MSSP more broadly. These activities are highly responsive to the National Heart Lung and Blood Institute’s Strategic Goals and Objectives, specifically objective 6, which aims to “optimize translational, clinical, and implementation research to improve health and reduce disease.”