STUDY OF HOSPITALS STAFFING ATTENDING PHYSICIAN ROLE FOR PATIENTS AT END OF LIFE

为了应对不断变化的政策和市场条件，医院必须决定如何为主治医生的角色配备人员，因为主治医生在协调患者护理方面发挥着关键作用，包括及时和安全地出院，以避免再次入院。2013年，医院现在因30天的再住院率高于预期而受到处罚。在这项应用中，我们建议研究严重功能障碍的NH居民中的3种典型疾病轨迹，以了解医院如何选择配备主治医生的角色：1)有高级认知障碍的痴呆症；2)慢性心力衰竭引起的终末性器官功能障碍；以及3)有肺炎并既往存在严重功能障碍的住院NH居民。痴呆症是一种长期严重功能障碍的典型疾病，医疗决策必须权衡数量与生活质量。后两个群体挑战卫生保健提供者协调卫生保健环境中的护理，以避免再次住院，并与患者和/或家庭就护理目标作出决定。使用2000年至2014年的MDS和Medicare索赔数据，我们建议描述医院为主治医生的角色配备工作人员的决定(目标I)，并检查这些决定对虚弱的老年NH居民经历的临床结果和医疗保健利用的影响(目标II)。截至2013年，医院面临着急性心肌梗死、充血性心力衰竭和肺炎患者30天再住院率高于预期的处罚。我们的第三个目标是评估这项新政策的预期和潜在的意外后果。最后的第四个目标建议进行8个案例研究，以了解30天再住院率较高和较低的医院如何组织医生服务，并与NH医务人员协调护理，为这3个拟议的虚弱、老年队列中的每一个提供高质量的护理 人。拟议的研究将提供政策相关信息，以检查观察到的特征和医院人员的戏剧性变化，主治医生的角色，以及评估ACA处罚对30天再住院率较高的医院的影响。

In response to changing policies and market conditions, hospitals must make decisions about how to staff the role of the attending physician since this individual plays a pivotal role in coordinating patient care, including timely and safe discharges that avoid hospital readmission. In 2013, hospitals are now penalized for higher than expected 30-day readmissions rates. In this application, we propose to study 3 paradigmatic illness trajectories among NH residents with severe functional impairment in order to understand how hospitals choose to staff the attending physician role: 1) dementia with advance cognitive; 2) end organ dysfunction from CHF; and 3) hospitalized NH residents with pneumonia with pre-existing severe functional impairment. Dementia is a paradigmatic illness with prolonged severe functional impairment where medical treatment decisions must weigh quantity vs. quality of life. The latter two cohorts challenge health care providers to coordinate care across health care settings to avoid hospital readmissions and to make decisions with the patient and/or family regarding the goals of care. Using the MDS and Medicare claims data from 2000 to 2014, we propose to characterize hospitals' decisions to staff the role of the attending physician (Aim I) and examine the impact of those decisions on clinical outcome and health care utilization experienced by frail elderly, NH residents (Aim II). As of 2013, hospitals are faced with penalties for having a higher than expected 30 day re-hospitalization rates for patients with acute myocardial infarction, congestive heart failure, and pneumonia. Our third aim is to estimate the intended and potential unintended consequence of this new policy. A final fourth aim proposes to conduct 8 case studies to understand how hospitals with higher and lower rates of 30-day readmission organize physician services and coordinate care with the NH medical staff to provide high quality of care for each of these 3 proposed cohorts of frail, older persons. The proposed research will provide policy relevant information to examine observed dramatic changes in characteristics and hospital staffing the role of the attending physician as well as evaluate the impact of ACA penalties for hospitals with higher rates of 30 days hospital readmissions.