The Impact of Quality Metrics on Outcomes Among Elderly Heart Failure Patients

项目摘要/摘要 1护理质量已成为提供者评价和补偿的重要组成部分。作为替代付款 2款车型越来越受欢迎，新的基于绩效的激励付款(MIPS)计划推出，质量如何定义，以及 3对患者、提供者和付款人来说，衡量标准将变得越来越重要。在心脏病学领域，大多数质量 4个指标基于大型随机试验的结果。虽然可靠，但随机试验在其 5可推广性，因为登记标准定义狭窄，某些患者群体的代表性不足。 6这可能导致一种疗法已被证明有效的人群与 7哪些质量指标要求它使用。反过来，这可以创建一个质量测量系统，在不经意间激励 8无证据的做法或不公平地惩罚某些提供者。一个例子是使用神经激素治疗 9例老年心力衰竭伴射血分数降低(HFrEF)。神经激素疗法，包括 10种血管紧张素转换酶抑制剂(ACEI)/血管紧张素II受体阻滞剂(ARB)和β-受体阻滞剂 11 HFrEF治疗的基石，它们的使用现在定义了HFrEF护理的质量。而神经激素疗法 12无疑有益于绝大多数高龄≥患者，75岁的老年患者在 13项里程碑式的研究，评估了这些药物的有效性和安全性。因为神经激素疗法带来了不平凡的 14副作用的风险，在某些老年人中，治疗的短期风险可能超过长期好处 15例患者。然而，目前，无论是临床指南还是质量指标都不能解释这种已知的 16名老年HFrEF受益人。为了更好地了解神经激素治疗对老年HFrEF患者的影响， 17确定如何最好地在老年HFrEF患者中使用神经激素治疗，并更有效地衡量护理质量 18在老年HFrEF患者中，提出了使用管理、登记和定性数据的三部分分析。这个 19项目的目标是(1)使用医疗保险数据来确定神经激素治疗的临床益处是否以及如何变化 20岁；(2)使用与联邦医疗保险数据相关联的国家登记数据来确定预测可能性的特征 21在老年HFrEF患者中受益于神经激素治疗并模拟靶向治疗的效果 22使用识别的特征进行治疗的方法；以及(3)使用半结构化的患者访谈来确定 23个方面的护理，定义了为老年HFrEF患者提供的“高质量护理”。这项工作有可能既提高 24为老年高危高危患者提供护理数量和生活质量，并改进我们目前的质量方法 25心力衰竭的测量。首先，对神经激素治疗结果的现有差异进行评估，按年龄， 26将确定问题的范围和改进的潜力。第二，患者层面的识别 与老年HFrEF中神经激素治疗受益(或伤害)可能性高相关的27个特征 28名患者将能够改善临床护理并改进当前的质量指标。最后，进行定性评估。 29%的老年HFrEF患者的优先事项将为未来的研究奠定基础，以发展下一代质量 包含患者偏好的30个指标。

Project Summary/Abstract 1 Quality of care has become a significant component of provider evaluation and reimbursement. As alternative payment 2 models gain popularity and the new Merit-Based Incentive Payment (MIPS) program rolls out, how quality is defined and 3 measured will become increasingly important for patients, providers and payers. In the field of cardiology, most quality 4 metrics are based on findings from large, randomized trials. While robust, randomized trials can be limited in their 5 generalizability, owing to narrowly defined enrollment criteria and the underrepresentation of certain patient populations. 6 This can result in a mismatch between the population in which a therapy has been proven effective and the population in 7 which quality metrics require it use. This, in turn, can create a system of quality measurement that inadvertently incentives 8 non-evidenced based practice or unfairly penalizing certain providers. An example is the use of neurohormonal therapy in 9 elderly patients with heart failure and reduced ejection fraction (HFrEF). Neurohormonal therapies, which include 10 angiotensin converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARB) and beta-blockers, are the 11 cornerstone of HFrEF therapy and their use now defines quality in HFrEF care. While neurohormonal therapies are 12 undoubtedly beneficial in the vast majority of HFrEF patients, elderly patients ≥75 years old were underrepresented in the 13 landmark studies that evaluated the efficacy and safety of these drugs. Since neurohormonal therapies carry a non-trivial 14 risk of side effects, it is possible that the short term risks of therapy outweigh the longer term benefits in certain elderly 15 patients. At present however, neither clinical guidelines nor quality metrics account for this known heterogeneity among 16 elderly HFrEF beneficiaries. To better understand the impact of neurohormonal therapy on elderly HFrEF patients, 17 determine how best to use neurohormonal therapy in elderly HFrEF patients and more effectively measure quality of care 18 among elderly HFrEF patients, a 3-part analysis using administrative, registry and qualitative data is proposed. The 19 project aims to (1) use Medicare data to determine whether and how the clinical benefits of neurohormonal therapy vary 20 by age; (2) to use the national registry data linked with Medicare data to determine characteristics that predict likelihood 21 to benefit from neurohormonal therapy among elderly HFrEF patients and simulate the effectiveness of a targeted 22 approach to therapy using the identified characteristics; and (3) to use semi-structured patient interviews to determine the 23 aspects of care that define “high quality care” for elderly HFrEF patients. This work has the potential to both improve the 24 quantity of care and the quality of life for elderly HFrEF patients as well as improve our current method of quality 25 measurement in heart failure. First, an assessment of existing variation in outcomes with neurohormonal therapy, by age, 26 will define the scope of the issue and the potential for improvement. Secondly, identification of the patient-level 27 characteristics associated with a high likelihood of benefit (or harm) from neurohormonal therapy among elderly HFrEF 28 patients will enable improved clinical care and the refinement of current quality metrics. Finally, a qualitative assessment 29 of elderly HFrEF patient priorities will lay the foundation for future research to develop the next generation of quality 30 metrics that incorporate patient preferences.