Evaluating Policies for Improving Surgical Care in the Elderly

描述（由申请人提供）：在美国，每年有超过50，000名医疗保险患者死于住院手术。有证据表明，提供者之间存在很大差异，这表明有很大的改进余地。为了改善老年人的手术护理，医疗保险和医疗补助服务中心（CMS）推出了几项政策。然而，这些政策在多大程度上改善结果和降低手术成本尚不清楚。因此，我们提出了一个系统的评估的影响，几个政策选择的质量和成本的外科护理在国家医疗保险的人口。考虑到这一目标，我们目前的建议有以下目标：目标1。评价CMS改进政策对手术结局的影响。我们将在全国医疗保险人群中对绩效工资、选择性转诊、捆绑支付和结果反馈进行评估。对于每一种政策方法，我们将利用一个自然实验（即，（五）过去五年实施的具体方案或政策。为了评估结果，我们将使用风险调整后的死亡率和并发症的程序，特别是针对政策。为了更好地控制医院病例组合和长期趋势，我们将使用差异中的差异方法。目标2.评估这些CMS政策对非目标手术条件的溢出效应。使用国家医疗保险数据，我们将检查患者接受相同外科医生护理或依赖相同医院资源的非靶向手术的结果。我们将评估这些政策是否产生了有益的溢出效应，或者在资源被转移到目标条件时造成了意想不到的伤害。目标3.评估这些政策对手术前后医疗保险支付的影响。我们将评估医疗保险支付的全方位服务，可以链接到并发症和低质量的护理。我们将包括支付给医院，医生，再入院和急性后护理。这项研究的结果将促进CMS和其他支付者的循证决策。随着改善护理的有效政策的实施，手术患者将成为这项研究的最终受益者。 公共卫生相关性：这项研究将对CMS政策制定者和手术患者产生直接的现实影响。这一建议的结果将为CMS提供关于提高质量和降低成本的各种举措的相对有效性的数据。由于CMS和其他支付者实施了改善护理的有效策略，手术患者将成为这项研究的最终受益者。

DESCRIPTION (provided by applicant): Each year in the United States, more than 50,000 Medicare patients die undergoing inpatient surgery. Evidence of wide variations across providers suggests substantial room for improvement. To improve surgical care in the elderly, the Center for Medicare and Medicaid Services (CMS) has launched several policies. However, the extent to which these policies improve outcomes and reduce costs in surgery is unknown. We therefore propose a systematic evaluation of the impact of several policy options on the quality and cost of surgical care in the national Medicare population. With this goal in mind, our current proposal has the following aims: Aim 1. To evaluate the impact of CMS improvement policies on surgical outcomes. We will conduct evaluations of pay-for-performance, selective referral, bundled payment, and outcomes feedback in the national Medicare population. For each policy approach, we will take advantage of a natural experiment (i.e., a specific program or policy implemented in the last 5 years). To assess outcomes, we will use risk-adjusted mortality and complications for the procedures specifically targeted by the policy. To better control for hospital case-mix and secular trends, we will use a difference-in-difference methodology. Aim 2. To evaluate the spillover effects of these CMS policies on untargeted surgical conditions. Using national Medicare data, we will examine outcomes for untargeted procedures for which patients receive care from the same surgeons or depend on the same hospital resources. We will assess whether these policies resulted in beneficial spillover effects or caused unintended harm as resources were diverted to the targeted conditions. Aim 3. To evaluate the impact of these policies on Medicare payments around the surgical episode. We will evaluate Medicare payments for the full range of services that can be linked to complications and poor quality care. We will include payments to the hospital, physicians, readmissions, and post-acute care. The results of this study will facilitate evidence-based policymaking by CMS and other payers. As effective policies for improving care are implemented, surgical patients will be the ultimate beneficiaries of this research. PUBLIC HEALTH RELEVANCE: This study will have immediate real-world impact for CMS policymakers and surgical patients. The results of this proposal will provide CMS with data on the comparative effectiveness of various initiatives for improving quality and decreasing costs. As effective strategies for improving care are implemented by CMS and other payers, surgical patients will be the ultimate beneficiaries of this research.