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死亡的主要原因 管理（VHA），它也是VHA的运营成本的主要组成部分。近年来，VHA采取了许多护理质量举措，以改善心脏病患者的健康状况。同时，VA临床运营的财政压力增加了，VHA越来越被迫优化其医疗保健的价值（即，在节约有限资源的同时提高成果）。虽然VHA不断收集和报告许多护理过程质量指标，以评估VA医疗中心（VAMC）的临床表现，但对VAMC水平的心血管结局和护理成本知之甚少。这种信息的缺乏使VHA领导层无法清楚地了解VAMC在提供高质量心血管护理以实现价值最大化方面的比较性能。我们的多学科团队在心血管结局和经济学方面经验丰富的研究人员建议比较两种广泛流行和高成本的心血管疾病-缺血性心脏病（IHD）和慢性心力衰竭（CHF）的结局和护理成本-从2010年到2014年财政年度，VA的150个VAMCs。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的退伍军人产生良好风险调整健康结果的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中最有利于获得最佳结果和经济效率的CHF/IHD护理的结构方面，特别关注几种高成本护理组成部分的当地频率的影响，包括：心血管成像、植入式器械使用、站外主要心血管护理和非选择性住院;和（3）深入探讨关键的临床，方案，和领导，以及通过与该国表现最好和表现最差的VAMC的领导层和临床提供者的访谈产生这些结果的因素。为了解决这些研究目标，我们将结合联合收割机数据从VA的国家病人护理数据库，VA的决策支持系统国家数据提取数据库，和VA的收费基础护理数据库，所有的VA的企业数据仓库。其他数据将从美国医院协会的年度医院调查和VA/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VA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，以研究医院级结局和心血管护理成本，同时控制CHF和IHD患者人群中VAMC之间的关键差异。我们将遵循这一定量分析，并对在一系列电话访谈中收集的信息进行定性评估，这些访谈是与行政和临床领导以及前5名VAMC的一线临床医生进行的， 就心血管护理价值而言，VAMC排在后5位。这种“扎根理论”定性分析将确定关键的机构，计划和领导因素，这些因素是高价值IHD和CHF护理中全国表现最好的VA医疗中心（VAMCs）的特征，为寻求改善整个VA卫生系统心血管护理的VA临床和运营领导者提供了关键蓝图。我们的结果随后将通过VA慢性心力衰竭和缺血性心脏病质量增强研究计划（QUERI）维护的提供商网络传达给VA心脏病学的关键政策和临床领导者，其领导者将与该项目的研究团队合作，作为研究设计和实施的共同研究者，以及研究结果的传播。

 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.