Cardiac care in specialty and general hospitals

描述（由申请人提供）：最近出现的心脏专科医院引起了广泛的争议。支持者认为，这样的医院提供更高质量和更低成本的护理，而批评者认为，专业医院“樱桃采摘”较低的严重程度和更有利可图的病人，没有明显改善病人的结果。之前的研究比较了心脏专科医院和综合医院，研究了有限数量的条件和程序，包括相对较少的专科医院，并且没有研究专科医院对同一医疗保健市场中综合医院的影响。这些初步研究的结果与一些研究不一致，这些研究表明专科医院的结局有所改善，而另一些研究则没有改善。此外，这些初始研究仅基于管理数据源，尽管这种方法具有潜在优势，但未使用临床登记。拟议研究的具体目的是比较在专科心脏病医院和竞争性综合医院接受护理的患者的结局，并研究专科医院对同一市场中综合医院的影响。这项为期四年的研究将涉及分析两个管理数据源（国家医疗保险和州一级索赔数据），并辅以两个专有临床登记处（胸外科医生协会国家数据库和国家心血管数据登记处）。该研究将通过检查在大量专业心脏病医院治疗的患者的结果来解决先前研究的局限性，这些患者患有广泛的疾病，包括急性心肌梗死和充血性心力衰竭患者以及接受经皮冠状动脉介入治疗，冠状动脉旁路移植术和瓣膜置换术的患者，使用管理和临床数据。对于每种诊断，将心脏专科医院的死亡率和并发症发生率与位于与专科医院相同的医疗保健市场内的竞争性综合医院的死亡率和并发症发生率进行比较。将使用三种互补方法来最大限度地减少选择偏倚（分层线性模型、倾向评分和工具变量），并调整重要的患者水平、医院水平和市场水平混杂因素。其他分析将评估新的心脏专科医院对位于相同医疗保健市场的竞争性综合医院的心脏容量和患者结局的影响。这些分析将为决策者、付款人、提供者和患者提供关于专科心脏病医院提供的相对护理质量的急需信息。

DESCRIPTION (provided by applicant): The recent emergence of specialty cardiac hospitals has generated widespread controversy. Proponents suggest that such hospitals deliver higher quality and lower cost care, while critics contend that specialty lospitals "cherry pick" lower severity and more profitable patients with no demonstrable improvements in patient outcomes. Prior studies comparing specialty cardiac and general hospitals have examined a limited number of conditions and procedures, have included relatively few specialty hospitals, and have not examined the impact of specialty hospitals on general hospitals in the same healthcare markets. The results of these preliminary studies have been inconsistent with some studies demonstrating improved outcomes in specialty hospitals and others demonstrating no improvement. Moreover, these initial studies have been based exclusively upon administrative data sources and have not utilized clinical registries despite the potential advantages of this approach. The specific aims of the proposed research are to compare the outcomes of patients receiving care in specialty cardiac and competing general hospitals and to examine the impact of specialty hospitals on general hospitals in the same markets. This four-year study will involve the analysis two administrative data sources (national Medicare and state-level claims data) supplemented by two proprietary clinical registries (the Society for Thoracic Surgeons National Database and the National Cardiovascular Data Registry). The research will address the limitations of prior studies by examining outcomes of patients treated in a larger number of specialty cardiac hospitals for a broad spectrum of conditions, including patients with acute myocardial infarction and congestive heart failure and patients undergoing percutaneous coronary interventions, coronary artery bypass graft surgery, and valve replacement surgery using both administrative and clinical data. For each diagnosis, mortality and complication rates in specialty cardiac hospitals will be compared with mortality and complication rates in competing general hospitals located within the same healthcare market as the specialty hospitals. Three complementary methods will be used to minimize selection bias (hierarchcial linear models, propensity scores, and instrumental variables) and adjust for important patient-level, hospital-level, and market-level confounders. Additional analyses will assess the impact of new specialty cardiac hospitals on the cardiac volumes and patient outcomes of competing general hospitals located within the same healthcare markets. Together these analyses will provide much needed information on the relative quality of care provided by specialty cardiac hospitals to policy makers, payors, providers and patients.