The Influence of Hospital Variability on the Management of Cancer-Associated Comp

描述(申请人提供)：癌症相关并发症的治疗质量，即那些直接可归因于癌症本身或由化疗和/或放射引起的并发症，很少受到关注。这尤其有问题，因为与癌症相关的并发症与严重的发病率有关，往往伴随着疼痛和不适，并且需要花费大量的医疗资源进行治疗。癌症相关并发症的管理因可用无数的治疗方案而变得更加复杂，其中许多都未经证实，而且与高昂的成本相关。对影响并发症护理分配的因素以及影响预后的因素知之甚少。患者接受的医疗保健及其相关的结果受许多患者、医生和医院因素的相互影响。对于急性住院患者的医疗条件，患者接受治疗的医院的特点起着至关重要的作用。越来越多的人认识到，医院之间在如何分配护理方面存在广泛的差异，这些实践模式的差异解释了很大一部分治疗差异。未参保和少数族裔患者 这些患者特别容易受到这些医院水平差异的影响，因为这些患者更有可能在临床和财政资源有限的设施接受护理，这可能会对质量产生不利影响。在这份提案中，我们将确定住院患者的治疗质量，这些患者的主要诊断是：发热性中性粒细胞减少症、恶性肿瘤高钙血症、食管炎和急性癌症相关性疼痛。对于每个与癌症相关的并发症，我们将确定治疗模式、治疗决定的基础因素，以及迅速启动以指南为基础的治疗对结果的影响。对于每种情况，我们将首先检查基于指南的治疗和非适应症治疗的使用情况。然后，我们将全面检查患者、医生和医院的特点以及医院之间的差异对以指南为基础的护理分配的影响。我们假设，不同医院之间的治疗有很大的差异，这是传统方法无法解释的。最后，我们将进行新的因果推断和调解分析，以确定通过基于指南的及时治疗对每个并发症的结果(住院时间、再入院时间、费用、非常规出院和死亡率)的直接和间接影响。除了包括一些新的统计方法外，这项建议还将利用一个非常适合这项研究的独特数据库 这些复杂的情况。这些研究的数据将立即产生可操作的结果，可用于指导实施以医院为基础的实用干预措施，以提高癌症相关并发症患者的护理质量。

DESCRIPTION (provided by applicant): The quality of treatment for cancer-associated complications, those complications directly attributable to the cancer itself or that result from chemotherapy and/or radiation, have received little attention. This is particularly problematic as cancer-associated complications are associated with significant morbidity, are often accompanied by pain and discomfort, and require the expenditure of substantial healthcare resources for treatment. The management of cancer-associated complications is compounded by the availability of a myriad of treatment options, many of which are unproven and associated with significant cost. Little is known about the factors that influence allocation of care for thes complications and what factors influence outcome. The health care a patient receives and its associated outcomes are influenced by the interplay of a number of patient, physician, and hospital factors. For acute inpatient medical conditions the characteristics of the hospital in which a patient is treated play a crucial role. There is growing recognition that there is widespread between-hospital variation in how care is allocated and that these differences in practice patterns explain a large portion of treatment variability. Uninsured and minority patients are particularly vulnerable to these hospital level disparities as these patients are disproportionately more likely to receive care at facilities with limited clinical and financial resources that may adversely affect quality. In this proposal we will determine the quality of treatment for hospitalized patients admitted with a primary diagnosis of: febrile neutropenia, hypercalcemia of malignancy, esophagitis, and acute cancer-associated pain. For each cancer-associated complication we will determine patterns of treatment, the factors that underlie treatment decisions, and the effect of prompt initiation of guideline-based therapy on outcomes. For each condition we will first examine the utilization of guideline-based and non-indicated treatments. We will then comprehensively examine the influence of patient, physician, and hospital characteristics as well as between- hospital variations on the allocation of guideline-based care. We hypothesize that there is substantial variation in treatment between hospitals that is unexplained by traditional measures. Finally, we will perform novel causal inference and mediation analyses to determine the direct and indirect effects operating through a mediator of prompt guideline-based treatment on outcomes (length of stay, readmission, cost, non-routine discharge and mortality) for each complication. In addition to including a number of novel statistical methodologies, this proposal will utilize a unique database ideally suited to the study of these complications. The data from these studies will lead to immediately actionable results that can be used to guide the implementation pragmatic hospital-based interventions to improve the quality of care for patients with cancer-associated complications.