Explaining Rising Heart Failure Mortality in Medicare

解释医疗保险中不断上升的心力衰竭死亡率

• 批准号: 9806392
• 负责人: Rishi Kumar Wadhera
• 金额: $ 17.25万
• 依托单位: BETH ISRAEL DEACONESS MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-07-15 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9806392
• 关键词: Accident and Emergency department; Acute; Advisory Committees; Affect; Age; Area; Automobile Driving; Award; Awareness; Biostatistical Methods; Cardiovascular system; Caring; Clinical; Clinical Investigator; Complex; Data; Data Set; Decision Making; Elderly; Emergency department visit; Financial Hardship; Foundations; Goals; Health Policy; Heart failure; Hospitalization; Hospitals; Incentives; Individual; Inpatients; Interview; Length of Stay; Low income; Medicare; Medicare claim; Medicine; Mentors; Neighborhoods; Outcome; Outcomes Research; Outpatients; Patient Care; Patient Preferences; Patient Triage; Patient-Focused Outcomes; Patients; Patterns of Care; Perception; Physicians; Policies; Population; Poverty; Prevalence; Program Development; Public Health; Qualitative Methods; Quality of Care; Reporting; Research; Research Personnel; Resources; Risk; Risk Factors; Site; Social Change; Structure; Surveys; Testing; Time; United States; Vulnerable Populations; Work; base; beneficiary; care delivery; care outcomes; career; career development; clinical care; deprivation; design; disadvantaged population; experience; federal policy; financial incentive; follow-up; high risk; hospital readmission; improved; improved outcome; innovation; insight; mortality; novel strategies; older patient; policy implication; pressure; profiles in patients; programs; readmission rates; residence; skills; social; social vulnerability; trend

! ! PROJECT(SUMMARY/ABSTRACT( The clinical and financial burden of heart failure (HF) among older adults in the United States is high, with over 400,000 hospitalizations and $30 billion in spending annually. After a decade of steady improvement in short- term mortality among older adults hospitalized with HF, mortality within 30 days of hospital discharge is now increasing in this population. Little is known, however, about the factors driving this concerning trend. This study proposes to use administrative and qualitative data to evaluate patient, hospital, and policy level factors that explain rising mortality. In Aim 1, we will use Medicare data to determine if increasing clinical and/or social risk among older adults hospitalized with HF, or worsening hospital care quality, explain recent trends in mortality. In Aim 2, we will examine whether the Hospital Readmissions Reduction Program (HRRP) - a federal policy that intended to improve HF care by financially penalizing hospitals with high 30-day readmission rates – has incentivized inappropriate post-discharge care strategies (i.e. avoiding indicated readmissions) that have been associated with increased mortality. Our preliminary data suggest that the rise in mortality is being driven by patients with HF who are not readmitted to the hospital, providing initial support for this hypothesis. In Aim 3, we will use semi-structured physician interviews to understand if their decision-making regarding the care of HF patients has changed since HRRP. In addition, we will interview patients with HF to explore their awareness and perception of this policy. These interviews will also be used to gather preliminary data on potential strategies to improve post-discharge HF care. The overarching goal of this proposal is to understand why short-term mortality among older adults with HF is rising in the United States, which may have significant clinical and policy implications. The first two aims of this analysis will inform whether more resources should be allocated to sites that care for clinically high-risk or socially disadvantaged populations and if current federal policies (HRRP) should be redesigned or eliminated. The third aim will lay the foundation for future research to develop and test novel strategies, based on physician and patient preferences, to improve post-discharge HF care. This research will be accomplished in the setting of a comprehensive career development program designed to provide Dr. Wadhera, an early career investigator and cardiologist, with the skills needed to become an independent investigator in cardiovascular medicine and health policy. His long-term career goal is to use large datasets at the population level, and qualitative methods at the individual level, to comprehensively evaluate the impact of health policies on cardiovascular care and outcomes. An outstanding mentoring team and advisory committee of established clinical investigators in the fields of cardiovascular medicine, outcomes research, health policy, and advanced biostatistical and qualitative methods will guide Dr. Wadhera in his transition to independence over the course of the award period. !

！ ！ 项目（摘要/摘要（ 美国老年人心力衰竭 (HF) 的临床和经济负担很高，超过 每年有 40 万人次住院治疗和 300 亿美元的支出。经过十年的稳步改进 因心力衰竭住院的老年人的足月死亡率，出院 30 天内的死亡率现为 这个人口数量不断增加。然而，人们对推动这一令人担忧的趋势的因素知之甚少。这 研究建议使用行政和定性数据来评估患者、医院和政策层面的因素 这解释了死亡率上升的原因。在目标 1 中，我们将使用医疗保险数据来确定是否增加临床和/或社会 因心力衰竭住院的老年人的风险或医院护理质量恶化，解释了最近的趋势 死亡。在目标 2 中，我们将研究医院再入院减少计划 (HRRP) 是否是联邦 旨在通过对 30 天再入院率高的医院进行经济处罚来改善心力衰竭护理的政策 – 激励了不适当的出院后护理策略（即避免指定的再入院）， 与死亡率增加有关。我们的初步数据表明，死亡率上升是由 未再次入院的心力衰竭患者，为这一假设提供了初步支持。瞄准 3、我们将使用半结构化的医生访谈来了解他们是否做出了有关护理的决策 自 HRRP 以来，心力衰竭患者发生了变化。此外，我们还将采访心力衰竭患者，以探讨他们的情况 对本政策的认识和看法。这些访谈还将用于收集初步数据 改善出院后心力衰竭护理的潜在策略。该提案的总体目标是了解 为什么美国老年人心力衰竭的短期死亡率不断上升，这可能对 临床和政策影响。该分析的前两个目标将告知是否应该投入更多资源 分配给照顾临床高风险或社会弱势群体的场所，并且如果当前联邦 政策（HRRP）应该重新设计或取消。第三个目标将为未来的研究奠定基础 根据医生和患者的喜好制定和测试新策略，以改善出院后心力衰竭 关心。这项研究将在制定全面的职业发展计划的情况下完成 旨在为早期职业调查员和心脏病专家 Wadhera 博士提供以下技能： 成为心血管医学和卫生政策的独立研究者。他的长期职业目标是 在人口层面使用大型数据集，在个体层面使用定性方法， 全面评估卫生政策对心血管护理和结果的影响。一个杰出的 由心血管领域现有临床研究人员组成的指导团队和咨询委员会 医学、结果研究、卫生政策以及先进的生物统计和定性方法将指导博士。 瓦德拉在获奖期间向独立过渡。 ！