Longterm Consequences for Veterans with Sepsis

描述(由申请人提供)： VHA在住院质量的科学测量和管理方面一直处于国际领先地位，从早期的全系统电子病历到住院患者评估中心(IPEC)的仔细基准。已经发展了大量的专门知识和基础设施来衡量住院护理的短期结果。尽管医院投入了大量精力来改善患者的长期结果，但很少有研究将医院与长期结果联系起来--也没有运营系统向医院提供结果反馈。为了开发一种方法来研究住院后的长期结果，首先将检查患有严重脓毒症的单一情况的患者。严重脓毒症是一种非常常见的、严重危及生命的疾病，由普通病房和VHA的重症监护病房的各种医生护理。脓毒症至少与公认的急性心肌梗死等高优先级疾病一样常见。目前，关于哪些严重脓毒症患者的不良长期结局风险最大的信息很少。此外，尽管有许多治疗严重脓毒症的高效疗法，医院在实施这些疗法方面也存在很大差异，但关于严重脓毒症后的长期结果在多大程度上受到医院护理的影响，信息很少。这项提案的基本目标是以严重脓毒症为模型条件，开发一个将急性住院治疗与长期结果联系起来的过程，并制定一项战略，以确定哪些医院表现良好，哪些医院需要改进。使用与2005-2010年所有VHA急性护理医院的医疗SAS文件和其他数据源相链接的IPEC患者水平数据的回顾队列，本建议的目标是：(1)确定住院期间严重脓毒症的发病时间，并完善严重脓毒症的自动化定义；(2)确定与不良长期结局风险升高相关的患者水平因素；(3)衡量医院之间在严重脓毒症后风险调整的长期结果方面的差异程度。该项目将作为一项回溯性队列研究，使用自2005年以来在美国住院的所有严重脓毒症退伍军人的现有数据。为了实现第一个目标，来自IPEC的数据将与结构化病历审查相结合，以定义管理数据的测量特征。作为探索性扩展，这些数据将与微生物学结果和详细化验值的自由文本搜索合并，以制定改进的严重脓毒症病例定义，用于以后的目标和未来的实施研究和质量改进活动。对于第二和第三个目标，VHA管理数据将进一步增强这些数据，这些数据将提供关于一年长期结果的数据：死亡率、医疗保健资源利用和疗养院使用。对于部分患者，将包括自我报告的健康状况，通过链接到患者的医疗体验调查。将进行多水平建模，以确定患者长期结果之间的异质性，以及这种异质性在多大程度上可归因于他们接受护理的部位。在未来，这一建议将导致对严重脓毒症的长期结果进行风险调整的措施，这些措施可用于：(A)向医院提供反馈，并确定改善严重脓毒症退伍军人护理的最佳做法；(B)改善退伍军人对长期结果的预测和风险分层；以及(C)作为了解和改善住院患者急性护理与长期结果之间的联系的典范条件。

DESCRIPTION (provided by applicant): The VHA has been an international leader in the scientific measurement and management of inpatient quality, from an early system-wide electronic medical record to the careful benchmarking of the Inpatient Evaluation Center (IPEC). Substantial expertise and infrastructure have been developed for the measurement of short- term outcomes for inpatient care. Although hospitals devote considerable energy to improving long-term outcomes for patients, there is little research linking hospitals to long-term outcomes-nor are there operational systems to provide feedback to hospitals on their results. In order to develop an approach to studying long-term outcomes after hospitalization, patients with a single condition, severe sepsis, will first be examined. Severe sepsis is a very common, acutely life-threatening condition cared for by a wide variety of physicians on both general care floors and in intensive care units throughout the VHA. Sepsis is at least as common as such recognized high priority conditions as acute myocardial infarction. There is currently little information about which patients with severe sepsis are at greatest risk for adverse long-term outcomes. Furthermore, although there are a number of highly effective therapies for severe sepsis, and hospitals vary widely in their implementation of those therapies, there is little information on the extent to which long-term outcomes after severe sepsis are affected by hospital care. The fundamental goal of this proposal is to use severe sepsis as a model condition in which to develop a process for linking acute inpatient care to long-term outcomes and to develop a strategy for identifying individual hospitals that are high performers and those in need of improvement. Using a retrospective cohort with patient-level data from IPEC linked to the Medical SAS files and other data sources for all VHA acute care hospitals for 2005-2010, the objectives of this proposal are to: (1) ascertain the timing of onset of severe sepsis during hospitalizations, and refine the automated definition of severe sepsis; (2) identify patient-level factors associated with an elevated risk for adverse long-term outcomes; and (3) measure the extent of variation between hospitals in risk-adjusted long-term outcomes after severe sepsis. This project will be performed as a retrospective cohort study using existing data on all Veterans hospitalized with severe sepsis in the United States since 2005. To meet the first objective, data from IPEC will be combined with structured medical record review to define the measurement characteristics of the administrative data. As an exploratory extension, this data will be merged with free text searching of microbiology results and detailed laboratory values, to develop an improved case definition of severe sepsis for use in later Aims and future implementation research and quality improvement activity. For the second and third objectives, these data will be further augmented by VHA administrative data which will provide data on 1- year long-term outcomes: mortality, healthcare resource utilization, and nursing home use. For a subset of patients, self-reported health status will be included, via a link to the Survey of Healthcare Experience of Patients. Multilevel modeling will be performed to determine the heterogeneity between patients' long-term outcomes, and the extent to which such heterogeneity is attributable to the site to which they received care. In the future, this proposal will lead to risk-adjusted measures of long-term outcomes for severe sepsis that can be used to: (a) provide feedback to hospitals and identify best practices to improve the care of Veterans with severe sepsis; (b) improve prognostication and risk stratification of Veterans for long-term outcomes; and (c) serve as a model condition in understanding and improving the link between acute care and long-term outcomes for inpatient hospitalizations more generally.