Effectiveness of Strategies to Improve Outcomes after Hospitalization for Acute Myocardial Infarction in Older Adults

改善老年人急性心肌梗死住院后预后的策略的有效性

• 批准号: 10576349
• 负责人: Sarwat I Chaudhry
• 金额: $ 54.62万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-03-01 至 2025-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10576349
• 关键词: Accounting; Acute myocardial infarction; Address; Affect; Age; Aging; Ambulatory Care; Biometry; Cardiac Catheterization Procedures; Cardiovascular system; Cognition; Collaborations; Cost Control; Data; Data Set; Data Sources; Diagnostic tests; Discharge Plannings; Disease; Echocardiography; Effectiveness; Elderly; Enrollment; Epidemiology; Evaluation; Event; Financial Hardship; Gait speed; Geriatric Assessment; Health Status; Health system; Home; Home Care Services; Hospitalization; Hospitals; Incentives; Inpatients; Insurance Coverage; Interview; Measures; Medical Records; Medicare; Modeling; National Heart, Lung, and Blood Institute; Outcome; Outpatients; Patient Discharge; Patient Outcomes Assessments; Patients; Physiological; Prognosis; Reporting; Research; Risk; Services; Severity of illness; Social support; Techniques; Time; Visit; care delivery; cohort; comorbidity; depressive symptoms; evidence based guidelines; follow-up; functional disability; high risk; hospital care; hospital readmission; improved; improved outcome; mortality; mortality risk; older patient; participant enrollment; participant interview; payment; performance based measurement; primary outcome; programs; risk prediction; risk prediction model

Acute myocardial infarction (AMI) is consistently ranked as one of the top five most expensive conditions billed to Medicare and has been the target of several cost containment measures, including Medicare’s Hospital Readmissions Reduction Program. To improve outcomes after AMI hospitalizations, payers have implemented public reporting, financial penalties, and alternative payment models that incentivize the assumption of financial risk such as capitation. These measures have not been accompanied by evidence-based guidelines on how health systems can improve outcomes after hospitalization. An impediment to such guidance has been an incomplete understanding of patient-level factors that may influence the effectiveness of strategies to improve post-AMI hospitalization outcomes as applied in real-world settings. Notably, 30% of patients hospitalized for AMI are age ≥ 75. These patients have lower physiologic reserve and more functional impairments, including those in cognition and physical capabilities, than younger patients. In the SILVER-AMI study, we enrolled 3041 patients age ≥ 75 hospitalized for AMI at 94 hospitals. The primary objective was to evaluate the contribution of functional impairments and geriatric conditions to improving risk prediction for mortality within 6 months of hospital discharge. The premise of the SILVER-AMI study was that risk prediction at the time of discharge could identify high-risk patients who might benefit from more intensive post-hospital care. Findings from SILVER-AMI have demonstrated that functional impairments substantially improve risk prediction for important outcomes. We did not obtain Medicare data in this study so could not examine strategies being deployed in an effort to improve post-AMI outcomes. The overall objective of this proposal is to refine our understanding of the impacts of home health care (HHC) (Aim 1), early outpatient care (Aim 2), and Medicare Advantage (MA) (Aim 3) after AMI hospitalization by examining their effects in the context of functional impairments and illness severity. We will focus on outcomes of primary importance to older patients, including “home days” (days alive out of the hospital and other inpatient facilities) and health status, as well as disease-specific outcomes of relevance post-AMI. We will merge data from the SILVER-AMI study with Medicare data to achieve our aims. Combining these data sources will afford us the unique opportunity of accounting for an array of rigorously assessed covariates that are not generally available in studies using only administrative data and to identify patients who may benefit most from post-discharge services. In addition to accounting for a rich array of measured confounders, we will employ advanced statistical techniques to address bias from unmeasured confounding. We have assembled a team with a track record of collaboration and expertise in cardiovascular outcomes, home health care, outpatient care delivery, epidemiology, and biostatistics. This hypothesis-driven research will leverage the most comprehensive set of data on functional impairments and geriatric conditions collected during AMI hospitalization on a large, national cohort to inform strategies to improve outcomes of importance to older patients.

急性心肌梗死（AMI）一直被列为五大最昂贵的条件之一， 医疗保险，并一直是几个成本控制措施的目标，包括医疗保险的医院 减少再入院计划。为了改善AMI住院治疗后的结局，付款人已经实施了 公开报告，财务处罚和替代支付模式，激励财务假设 按人头计算等风险。这些措施并没有伴随着关于如何 卫生系统可以改善住院后的结果。这种指导的一个障碍是 对可能影响改善策略有效性的患者层面因素的不完全理解 AMI后住院治疗的结果，如在现实世界中应用。值得注意的是，30%的住院患者 AMI年龄≥ 75岁。这些患者的生理储备较低，功能障碍较多，包括 在认知和身体能力方面，比年轻患者更好。在SILVER-AMI研究中，我们招募了3041名 94家医院年龄≥ 75岁的AMI住院患者。主要目的是评价 功能障碍和老年疾病，以改善6个月内死亡率的风险预测 出院SILVER-AMI研究的前提是出院时的风险预测可以 确定可能受益于更密集的出院后护理的高危患者。SILVER-AMI的结果 已经证明，功能障碍大大提高了重要结果的风险预测。我们 在这项研究中，我没有获得医疗保险数据，因此无法检查为改善医疗保险而部署的策略。 AMI后的结果。本提案的总体目标是使我们更好地理解 AMI后的家庭卫生保健（HHC）（目标1）、早期门诊护理（目标2）和Medicare Advantage（MA）（目标3） 在功能障碍和疾病严重程度的背景下，通过检查其影响来评估住院情况。我们将 重点关注对老年患者至关重要的结果，包括“居家日”（出院后存活的天数 和其他住院设施）和健康状况，以及AMI后相关的疾病特异性结果。我们 我们将把SILVER-AMI研究的数据与医疗保险数据合并，以实现我们的目标。结合这些数据 来源将为我们提供一系列严格评估的协变量的独特机会， 在仅使用管理数据的研究中通常不可用，并确定可能受益最多的患者 从出院后的服务。除了考虑大量可测量的混杂因素外，我们还将采用 先进的统计技术，以解决未测量的混杂偏倚。我们组建了一个团队 在心血管结局、家庭医疗保健、门诊护理方面的合作和专业知识记录 交付、流行病学和生物统计学。这种假设驱动的研究将利用最全面的 一组关于AMI住院期间收集的功能障碍和老年状况的数据， 国家队列，为改善老年患者重要结局的战略提供信息。