Hospital strategies to improve outcome performance

描述(由申请人提供)：尽管十年来一直在努力改善对急性心肌梗死(AMI)患者的护理，但不同医院的AMI后患者死亡率仍然存在很大差异。2003年，医院经风险调整后的30天死亡率从11%到23%不等，相差超过两倍。虽然患者生存是住院的一个基本目标，但我们对风险调整后短期死亡率较低的医院的不同之处知之甚少。大量的医疗保健组织理论认为，医院结构、流程和内部环境可能会影响医院的运营和财务结果；然而，关于它们对临床结果的影响，例如风险调整后的死亡率，特别是在急性心肌梗死患者中，我们缺乏经验证据。我们将使用混合方法来：1)生成可能与急性心肌梗死患者的医院风险调整后30天死亡率相关的关于医院特定努力的假设(表征为使能结构、护理流程和医院内部环境)；以及2)确定与急性心肌梗死患者的医院风险调整后30天死亡率统计相关的医院努力。这种方法以一种互补的方式使用定性和定量研究来产生假设，然后检验假设。我们使用一个经过验证的风险调整死亡率模型和分层的广义线性模型来检验风险调整死亡率在医院水平的变化。这一风险调整模型已得到国家质量论坛的认可，并计划在2007年被医疗保险和医疗补助服务中心(CMS)用作公开报告的质量指标。缺乏关于医院水平风险调整死亡率差异的证据是我们目前关于如何改善预后的知识的一个严重缺口。这项拟议的研究将为循证努力提高医院在急性心肌梗死患者风险调整后30天死亡率方面的表现提供基础。我们将与CMS、JCAHO、美国心脏病学会(ACC)、美国卫生协会(AHA)、退伍军人管理局(VA)和VHA合作制定传播战略。

DESCRIPTION (PROVIDED BY APPLICANT): Despite a decade of efforts to improve care for patients with acute myocardial infarction (AMI) there remains substantial variation across hospitals in patient mortality rates after AMI. The risk-adjusted 30 day mortality rates of hospitals in 2003 ranged from 11% to 23%, more than a two-fold difference. Although patient survival is a fundamental goal of the hospitalization, we know little about what distinguishes hospitals with lower risk-adjusted short-term mortality rates. A substantial body of health care organizational theory posits that hospital structures, processes, and internal environments may influence hospital operational and financial outcomes; however, we have less empirical evidence concerning their influence on clinical outcomes; such as risk-adjusted mortality rates, especially among patients with AMI. We will use a mixed methods approach to: 1) generate hypotheses regarding hospital-specific efforts (characterized as enabling structures, processes of care, and hospital internal environments) that may be associated with hospital risk-adjusted 30 day mortality rates for patients with AMI; and 2) determine the hospital effort that are statistically associated with hospital risk-adjusted 30 day mortality rates for patients with AMI. This methodology employs qualitative and quantitative research in a complementary fashion to generate and then to test hypotheses. We employ a validated, risk-adjusted mortality model and hierarchical generalized linear models to examine hospital-level variation in risk-adjusted mortality. This risk-adjustment model has been endorsed by the National Quality Forum and slated for use by the Centers for Medicare & Medicaid Services (CMS) as a publicly reported quality indicator in 2007. The lack of evidence about what accounts for hospital-level variation in risk -adjusted mortality rates is a critical gap in our current knowledge about how to improve outcomes. The proposed study will provide the foundation for evidence-based efforts to elevate hospital performance in risk-adjusted 30-day mortality for patients with AMI. We will work on dissemination strategies with CMS, JCAHO, American College of Cardiology (ACC), American Health Association (AHA), the Veteran's Administration (VA), and the VHA.