Estimating Hospital Outcome Quality: Applications to Pay-for-Performance

项目描述（由申请人提供）：拟进行的项目将涉及两个主要研究领域，即质量测量和支付政策改革，以提高医疗保健的价值。第一个涉及评估和设计的结果质量和成本的估计，以概况医疗保健提供者的表现。本研究将评估现有结果绩效评估器的性能，提出新的评估器，并验证这些评估器的性能，以描述医院和医生实践的质量、成本和效率。我将从事的第二个研究领域是对马萨诸塞州医疗补助（MassHealth）医院绩效薪酬（P4P）计划的评估。我将测试P4P计划对该计划激励的领域（产妇和新生儿护理、社区获得性肺炎、手术感染预防、儿科哮喘）的质量和成本的影响。我还将评估该项目对种族和民族差异的影响。为了评估结果测量的性能，将构建仿真模型，并设计和实施一系列蒙特卡罗仿真实验。基本方法如下：假设的提供者被随机分配一个“真实”结果评分、一个绩效改善轨迹、一个患者风险评分、一个样本量和一个样本量轨迹。然后为每个提供者创建一个与样本量成反比的随机冲击。观察结果得分，作为真实结果质量、患者风险和随机冲击的函数，为每家医院创建。仅使用观察结果的信息，然后使用候选结果估计器估计真实结果，并比较这些估计器的性能。然后，这些估计器的性能将使用国家医疗保险数据和马萨诸塞州的数据为医院和医生进行验证。为了评估大众健康计划对质量、成本和种族和民族差异的影响，我将借鉴我以前研究中使用的方法。这将涉及使用面板数据计量经济学技术来测试马萨诸塞州医院是否提高质量和降低成本后，为大众健康病人的计划实施。为了检验该计划对差异的影响，我将测试该计划实施后医院内部质量差异和医院之间质量差异的减少。优秀的导师团队以及完善的教育和职业发展计划将为我的研究提供所需的技能和知识。我的导师是医疗保健支付和融资、质量测量、组织研究、卫生经济学和比较有效性领域的领导者。此外，我的导师们在他们的研究中运用了经济学、政治学、社会学和临床实践的见解和观点，为我提供了一个丰富多样的知识环境，我可以从中吸取指导。在我的职业发展规划中，我将提高我的方法论和编程能力，学习更多负责任的研究行为，获得临床实践和医疗组织的知识，并在一些全国性的会议上展示我的研究成果并与同事互动。成功实现我的K01建议目标的研究将具有重要的政策相关性。拟议的研究将增加我们对绩效薪酬和公共质量报告中使用结果衡量标准的认识，同时也通过对马萨诸塞州计划的评估，为绩效薪酬的有效性提供进一步的证据。虽然雄心勃勃，但我的研究成果记录表明，我有能力进行实现这些目标的研究。此外，为K01进行的课程作业和应用研究将增加我的研究技能，增强我实现这些目标的能力。在与我的导师合作进行这项研究后，我将在P4P和质量测量领域确立自己的研究地位，并在这些领域为自己定位R01资助。

DESCRIPTION (provided by applicant): The proposed project will pursue two major areas of research related to quality measurement and payment policy reform to improve value in healthcare. The first pertains to the evaluation and design of estimators of outcome quality and cost in order to profile the performance of healthcare providers. This research will evaluate the performance of existing estimators of outcome performance, propose new estimators, and validate the performance of these estimators to profile the quality, cost, and efficiency of hospitals and physician practices. The second area of research I will pursue is an evaluation of the Massachusetts Medicaid (MassHealth) hospital-based pay-for-performance (P4P) program. I will test the effect of the P4P program on quality and cost for the areas incentivized in the program (maternity and newborn care, community acquired pneumonia, surgical infection prevention, pediatric asthma). I will also estimate the effect of the program on racial and ethnic disparities. To evaluate the performance of outcome measures, a simulation model will be constructed and a series of Monte-Carlo simulation experiments will be designed and implemented. The basic approach is as follows: hypothetical providers are randomly assigned a "true" outcome score, a performance improvement trajectory, a patient risk score, a sample size, and a sample size trajectory. A random shock, inversely associated with sample size, is then created for each provider. Observed outcome scores, derived as a function of true outcome quality, patient risk, and the random shock are created for each hospital. Using only information on observed outcomes, true outcomes are then estimated using the candidate outcome estimators and the performance of these estimators is compared. The performance of these estimators will then be validated for hospitals and physicians using national Medicare data and data from Massachusetts. To evaluate the effect of the MassHealth program on quality, costs, and racial and ethnic disparities, I will draw on methods employed in my previous research. This will involve the use of panel data econometric techniques to test whether Massachusetts hospitals increased quality and decreased cost for MassHealth patients after the program was implemented. To examine the effect of the program on disparities, I will test for reductions in both within-hospital disparities in quality and between-hospital disparities in quality after the program was implemented. The skills and knowledge required to pursue my proposed research will be bolstered by an outstanding group of mentors and a robust education and career development plan. My mentors are leaders in the fields of payment and financing of healthcare, quality measurement, organizational research, health economics, and comparative effectiveness. Further, my mentors employ insights and perspectives from economics, political science, sociology, and clinical practice in their research, providing a rich and diverse intellectual environment from which I can draw upon as a mentee. In following my career development plan, I will enhance my methodological and programming skills, learn more about the responsible conduct of research, acquire knowledge of clinical practice and medical organization, and present my research findings and interact with colleagues at several national conferences. Research that successfully fulfills the aims of my K01 proposal will have important policy relevance. The proposed research will add to our knowledge about the use of outcome measures in pay-for-performance and public quality reporting while also providing further evidence about the effectiveness of pay-for- performance through the evaluation of the Massachusetts program. While ambitious, my track record of research achievement shows that I am capable of conducting research that achieves these aims. Further, the coursework and applied research conducted for the K01 will augment my research skills, enhancing my ability to achieve these aims. After collaborating with my mentors on this research, I will be have established myself as a researcher in the fields of P4P and quality measurement, positioning myself for R01 grants in these areas. PUBLIC HEALTH RELEVANCE: The proposed project has the potential to positively impact public health by creating more accurate estimators of healthcare provider outcome quality and cost and by contributing to the understanding of the effect of hospital-based pay-for-performance. This research can be used to design payment policy that creates stronger incentives for value and quality improvement in healthcare.