Understanding optimal delivery systems for cancer care

描述（由申请人提供）：不同医院和卫生系统的癌症治疗质量和成本差异很大。大量研究表明，效果较好的医院往往有大量病例，并明确关注癌症治疗。这些和其他数据促使许多人提倡建立专门的癌症医院——所谓的“重点工厂”——作为实现更有效的癌症治疗的最佳输送系统。然而，《平价医疗法案》（Affordable Care Act）的改革，包括责任医疗组织（Accountable Care Organizations， ACO），正在改变这种医疗模式。尽管支持者认为，ACOs将通过鼓励以前不一致的医院和医生向综合输送系统发展来提高效率，但其他人担心，对于患有复杂癌症诊断的患者，预期的好处将不会累积，而且ACOs将阻碍转诊到拥有最优秀癌症专业知识的医院。为了探讨这一问题，我们提出了一项研究，全面评估美国癌症护理服务模式与质量、结果和成本之间的关系。在第一个目标中，我们将研究护理提供模式对癌症护理质量的影响。使用国家医疗保险索赔和相关的SEER-Medicare数据，我们将确定乳腺癌、肺癌、前列腺癌和胰腺癌患者的队列。然后，我们将根据遵循指南建议和/或国家认可的质量措施的水平，比较不同护理交付模式提供的癌症护理的质量。我们认为，以癌症为重点的医院通常会有更高的依从性，部分原因是它们更集中于特定疾病的专业知识。在第二个目标中，我们将评估护理提供模式和结果之间的关系，包括手术死亡率、并发症、住院和长期生存。我们假设在以癌症为中心的医院接受治疗的患者将有更好的死亡率结果，而更大的输送系统整合将与更少的住院治疗相关。在第三个目标中，我们将检查与癌症相关的支出

DESCRIPTION (provided by applicant): The quality and cost of cancer care vary widely across hospitals and health systems. A large body of research indicates that hospitals with better outcomes tend to have large case volumes and a defined focus on cancer care. These and other data have prompted many to advocate for specialized cancer hospitals-so-called "focused factories"-as the best delivery system for achieving more efficient cancer care. However, reforms in the Affordable Care Act, including Accountable Care Organizations (ACO), are moving care away from this model. Although proponents argue that ACOs will improve efficiency by encouraging previously unaligned hospitals and physicians to evolve toward integrated delivery systems, others worry that the intended benefits will not accrue for patients with complex cancer diagnoses, and that ACOs will discourage referrals to hospitals with the greatest cancer expertise. To explore this issue, we propose a study that evaluates comprehensively the relationship between care delivery models and the quality, outcomes, and cost of cancer care in the United States. In the first aim, we will examine the impact of care delivery models on the quality of cancer care. Using national Medicare claims and linked SEER-Medicare data, we will identify cohorts of patients with breast, lung, prostate, and pancreatic cancer. We will then compare the quality of cancer care provided in different care delivery models based on levels of adherence with guideline recommendations and/or nationally-endorsed quality measures. We posit that cancer-focused hospitals will often have higher levels of adherence, due in part to their greater concentration of disease-specific expertise. In the second aim, we will assess the association between care delivery models and outcomes, including operative mortality, complications, hospitalizations, and long-term survival. We hypothesize that patients treated in cancer-focused hospitals will have better mortality outcomes, while greater delivery system integration will correlate with fewer hospitalizations following initial cancer therapy. In the third aim, we will examine cancer-related expenditures for these patient cohorts as they vary over time after diagnosis. We will also assess payments related to different clinical services including surgical procedures, systemic therapy, end-of-life care, and non-cancer-related treatments. We expect that cancer-focused hospitals will achieve savings around episodes of surgical care, and that patients treated in more integrated delivery systems will have lower longitudinal costs for their cancer care. Results from this study will prove invaluable to CMS policymakers and other stakeholders as they debate whether delivery system reforms deemed good for healthcare in general are also good for patients with cancer.