Improving the Quality of Health Systems for the Very Old

描述(由申请人提供)：人们普遍认为，美国的医疗保健体系无法满足美国人口中增长最快的部分--年龄最大的老年人--的需求。公共报告和绩效工资倡议已经在进行中，以解决目前交付系统质量参差不齐的问题。然而，人们越来越担心，目前的努力可能会通过重点衡量对为年轻人群制定的临床指南的遵守情况，从而伤害虚弱的老年人。这些指南提倡可带来长期死亡益处但可能产生短期风险的干预措施。年老体弱的人的寿命缩短可能意味着他们增加了风险，而没有受益。我们认为，可以使用以患者为中心的价值观，而不是以疾病为基础的指标，作为衡量的概念框架，创建有效的高龄老年人卫生保健绩效衡量标准。作为一名初级研究员，我的长期目标是发展一项研究事业，致力于开发、测试和实施衡量高龄老年人医疗保健系统质量的创新方法。这项提议的目标是建立必要的技能和试点数据，以成为这一领域的独立调查者。具体的职业发展目标是：(1)培养评估最年长老年人的价值或护理需求的专门知识；(2)发展使用、整合和分析调查数据和包括医疗保险索赔和最低数据集在内的各种行政索赔的高级专门知识；(3)完善制定和应用业绩衡量所需的统计分析和建模技能。这项提案的研究目标是在两个临终关怀力度不同的卫生系统中，利用调查和基于索赔的方法，开发和试行反映以患者为中心的高龄老人保健价值观的质量衡量标准。具体的研究目标是：(1)开发一种调查工具，衡量80岁以上的老年人或其照顾者对个性化选择的支持程度；(2)开发基于索赔的指标，从患者体验的角度评价患者价值的护理过程(例如。(3)在两个特定的医疗系统中试行多模式质量措施，并探索关于支持以患者为中心的决策与高龄人群的临床服务之间的关系的假设。相关性：数十亿美元被花费在为高龄老人提供急性和长期护理上。预计这一人口将翻两番，这使得公共卫生迫切需要以最低的成本提供尽可能高质量的医疗服务。这项提案的目标是制定监测和提高高龄老人护理质量所需的质量措施。

DESCRIPTION (provided by applicant): There is broad agreement that the U.S. health care system fails to meet the needs of the most rapidly growing segment of the U.S. population - the oldest old. Public reporting and pay for performance initiatives are already underway to address the uneven quality of the current delivery system. There is growing concern, however, that current efforts could harm the frail elderly by focusing on measuring adherence to clinical guidelines developed for younger populations. These guidelines promote interventions that lead to long-term mortality benefit but may engender short-term risk. The shortened survival of the very old or frail may mean they accrue the risks without benefit. We believe that valid measures of performance in health care for the oldest old can be created using patient-centered values, rather than disease-based indicators, as the conceptual framework of measurement. As a junior investigator, my long term goal is to develop a research career devoted to developing, testing, and implementing innovative approaches to measuring health care system quality for the oldest old. The goals of this proposal are to build the necessary skills and the pilot data to become an independent investigator in this field. The specific career development aims are: (1) to develop expertise in assessment of values or care needs of the oldest old; (2) to develop advanced expertise in the use, integration, and analysis of survey data and a diverse group of administrative claims including Medicare claims and the Minimum Data Set; (3) to refine skills in statistical analysis and modeling needed for the development and application of performance measures. The research goal of this proposal is to develop and pilot test, in two health systems that differ in aggressiveness of end-of-life care, quality measures that reflect patient-centered values in health care for the oldest old using survey and claims-based methods. The specific research aims are: (1) to develop a survey instrument that measures support for individualized choices for people older than 80 years of age or their caregivers; (2) to develop claims-based indicators of patient-valued processes of care in terms of patient experience (ex. continuity) and clinical services (nursing home time and end-of-life care); and (3) to pilot test the multi-modal quality measures in two specific health system and explore hypotheses about the relationships between support for patient-centered decisions and continuity with clinical services among the very old. Relevance: Billions of dollars are spent on providing acute and long-term care to the very old. The projected quadrupling of this population creates a public health imperative to provide the highest quality care possible at the lowest cost. The goal of this proposal is to create the measures of quality that are needed to monitor and improve the quality of care for the very old.