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，医院必须决定如何配备主治医生，因为主治医生在协调患者护理方面起着关键作用，包括及时和安全出院，避免再次住院。2013年，医院因超过预期的30天再入院率而受到处罚。在这个应用中，我们建议研究三种典型的疾病轨迹在NH居民严重的功能障碍，以了解医院如何选择工作人员的主治医生的角色：1)痴呆症与早期认知；2)终末器官功能障碍；3)住院的NH居民中既有严重功能障碍的肺炎。痴呆症是一种典型的疾病，伴有长期严重的功能障碍，医疗决策必须权衡生活的数量和质量。后两类人群对卫生保健提供者提出了挑战，要求他们协调各卫生保健机构的护理，以避免再次住院，并与患者和/或家属就护理目标做出决定。利用2000年至2014年的MDS和医疗保险索赔数据，我们建议表征医院对主治医生角色的决定（目的一），并检查这些决定对临床结果和体弱体弱的老年人、NH居民的医疗保健利用的影响（目的二）。截至2013年，医院对急性心肌梗死、充血性心力衰竭和肺炎患者的30天再住院率高于预期，将面临处罚。我们的第三个目标是估计这项新政策的预期后果和潜在的意外后果。最后的第四个目标建议进行8个案例研究，以了解30天再入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，为这三个拟议的体弱、老年人队列中的每一个提供高质量的护理

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.