Costs and Outcomes of Chronic Heart Disease Care in the VHA

 描述(由申请人提供)： 心血管疾病是参加退伍军人健康计划的退伍军人的主要死亡原因 行政管理费用(VHA)，也是VHA运营成本的一个主要组成部分。近年来，VHA采取了许多提高护理质量的举措，以改善心脏病患者的健康状况。与此同时，退伍军人管理局临床业务的财政压力增加，VHA越来越被迫优化其医疗保健的价值(即在节省有限资源的同时改善结果)。虽然VHA不断收集和报告大量护理过程质量指标，以评估退伍军人医疗中心(VAMC)的临床表现，但VAMC水平上的心血管结果和护理成本知之甚少。由于缺乏信息，VHA的领导层无法清楚地了解VAMC在提供最大价值的高质量心血管护理方面的相对表现。我们由心血管结果和经济学领域经验丰富的多学科研究人员组成的多学科团队建议比较2010财年至2014财年退伍军人管理局150家VAMC中两种广泛流行的高成本心血管疾病-缺血性心脏病(IHD)和慢性心力衰竭(CHF)-的结果和护理成本。该研究项目的具体目标是：(1)确定在这五年期间持续为患有IHD和CHF的退伍军人提供良好风险调整后健康结果的VAMC，并量化与产生这些结果相关的护理成本；(2)确定和量化这些VAMC中最有利于最佳结果和经济效益的CHF/IHD护理的结构方面，特别关注几个高成本护理组成部分的当地频率的影响，包括：心血管成像、植入性设备利用、站外主要心血管护理和非选择性住院；以及(3)通过采访该国表现最好和表现不佳的VAMC的领导层和临床提供者，深入探讨产生这些结果的关键临床、计划和领导力以及因素。为了达到这些研究目标，我们将结合来自退伍军人管理局的全国患者护理数据库、退伍军人管理局的决策支持系统国家数据摘录数据库和退伍军人管理局的费用基础护理数据库的数据--所有这些都保存在退伍军人管理局的企业数据仓库中。其他数据将从美国医院协会的年度医院调查以及退伍军人管理局/医疗保险和医疗补助服务中心的数据中获得，这些数据可从退伍军人管理局信息资源中心获得。将使用分层广义线性模型进行多变量统计分析，以调查医院级别的结果和心血管护理成本，同时控制CHF和IHD患者群体中VAMC的关键差异。在这一定量分析之后，我们将对通过一系列电话采访收集的信息进行定性评估，访谈对象包括行政和临床领导层以及排名前5位的VAMC和 在心血管护理价值方面排名垫底的5种VAMC。这一“扎根理论”定性分析将确定在高价值IHD和CHF护理方面，美国顶尖退伍军人医疗中心(VAMCs)的关键制度、计划和领导因素，为退伍军人管理局临床和运营负责人寻求改善退伍军人管理局整个医疗系统的心血管护理提供关键蓝图。我们的研究结果随后将通过退伍军人管理局的慢性心力衰竭和缺血性心脏病质量提高研究计划(QUERI)维护的提供者网络传达给退伍军人事务部心脏病学的主要政策和临床领导者，这些提供者网络的领导者将作为研究团队的合作伙伴，共同设计和实施研究，并传播研究结果。

 DESCRIPTION (provided by applicant): Cardiovascular disease is the leading cause of death among veterans enrolled in the Veterans Health Administration (VHA), and it is also a major component of the VHA's operating costs. In recent years, VHA has undertaken numerous quality-of-care initiatives to improve health outcomes in patients with heart disease. Simultaneously, fiscal pressures on VA's clinical operations have increased, and the VHA's is increasingly compelled to optimize the value of its health care (i.e., improve outcomes while conserving limited resources). While VHA continuously collects and reports numerous process-of-care quality measures to assess clinical performance across VA medical centers (VAMCs), there is much less known about cardiovascular outcomes and costs of care at the VAMC level. This absence of information prevents VHA leadership from having a clear picture of the comparative performance of VAMCs in providing high-quality cardiovascular care that maximizes value. Our multi-disciplinary team of highly experienced investigators in cardiovascular outcomes and economics proposes to compare the outcomes and costs of care for two widely prevalent and high-cost cardiovascular conditions-ischemic heart disease (IHD) and chronic heart failure (CHF)-across the VA's 150 VAMCs from fiscal year 2010 to 2014. The specific aims of the research project are: (1) to identify the VAMCs that consistently produced excellent risk-adjusted health outcomes for veterans with IHD and CHF during this five-year period and quantify the costs of care associated with producing these outcomes; (2) to identify and quantify the structural aspects of CHF/IHD care at these VAMCs that are most conducive to optimal outcomes and economic efficiency, with a particular focus on the influence of the local frequency of several high-cost components of care, including: cardiovascular imaging, implantable device utilization, off-station major cardiovascular care, and non-elective hospitalizations; and (3) to explore in depth the key clinical, programmatic, and leadership, and factors that produced these outcomes via interviews with the leadership and clinical providers at that nation's top-performing and low-performing VAMCs. To address these research aims, we will combine data from the VA's National Patient Care Databases, the VA's Decision Support System National Data Extract databases, and the VA's Fee Basis Care Database-all housed at the VA's Corporate Data Warehouse. Additional data will be obtained from the American Hospital Association's Annual Hospital Survey and from the VA/Centers for Medicare and Medicaid Services data available from the VA Information Resource Center. Multivariable statistical analyses using hierarchical generalized linear models will be conducted to investigate hospital-level outcomes and costs of cardiovascular care while controlling for key differences across VAMCs in their CHF and IHD patient populations. We will follow this quantitative analysis with a qualitative assessment of information collected in a series of telephone-based interviews with administrative and clinical leadership as well as front-line clinicians at the top 5 VAMCs and bottom 5 VAMCs in terms of cardiovascular care value. This "grounded theory" qualitative analysis will identify the key institutional, programmatic, and leadership factors that characteriz the nation's top-performing VA Medical Centers (VAMCs) in high-value IHD and CHF care, providing a critical blueprint to VA clinical and operations leaders seeking to improve cardiovascular care throughout the VA's health system. Our results subsequently will be communicated to key policy and clinical leaders in VA cardiology via the provider networks maintained by the VA's Chronic Heart Failure and Ischemic Heart Disease Quality Enhancement Research Initiatives (QUERIs), whose leaders will partner with the project's research team as co-investigators in the design and conduct of the study, as well as the dissemination of the research results.