THE IMPACT OF PUBLIC REPORTING ON OUTCOMES AND CASE SELECTION FOR PCI

项目摘要 候选人：我的职业目标是成为一名独立的研究人员在护理质量和心血管疾病。 为此，我很幸运地从医学院开始就与大量的研究导师一起工作，并希望 通过以患者为导向的研究职业发展奖继续这样做。我完成了原创 研究以及正式的研究培训在杜克临床研究所在医学院和 住院医师;最近，我在布里格姆担任心血管医学的临床研究员， 妇女医院（BWH），完成了我的公共卫生硕士学位，专注于临床有效性 在哈佛公共卫生学院（HSPH），现在担任研究员在司 BWH的心血管医学以及HSPH的卫生政策和管理部。我 广泛的研究兴趣是了解在质量上的广泛变化的基础因素， 我们在全国范围内看到的心血管疾病护理的结果，以及基于政策的 在临床质量和患者结局方面的质量改进工作。公开报道是一个特殊的领域， 兴趣;政策制定者将公开报告视为提高透明度的潜在有效工具 并推动医疗保健的改善。随着对成本和质量的日益重视， 在最近通过的《责任关怀法》的推动下，人们普遍认为， 报告工作将继续扩大，因此这是我特别感兴趣的一个领域。 环境：我提出的职业发展计划将在三个环境中进行。第一种是HSPH; 该项目需要的一项具体的新技能是定性研究，包括访谈和调查。 这是健康服务研究的关键技能，我计划在HSPH学习更多课程，并寻求 来自在这些领域具有专业知识的同事和教师的具体指导。第二个设置是 HSPH的卫生政策和管理部门。我的主要导师，杰哈博士，和共同导师，博士。 爱泼斯坦，都有他们的主要教师任命在这个部门，都是国家承认的 在衡量护理质量和护理差异方面的领导者;他们都有丰富的导师经验 并致力于通过指导、建议和研究来帮助我实现职业目标 协作第三个地方是BWH心血管医学部，我的共同导师Dr。 Resnic有他的主要任命。Resnic博士与马萨诸塞州卫生部密切合作， 公共卫生对他们目前的公共报告工作，因此有这个主题的重要知识。 参与“组织”的活动将使我不仅能够了解治疗方面的显著进展， 通过一系列临床会议和研究会议， 我希望我能继续发展各种关系，以便在未来实现富有成效的合作。 研究：虽然关注护理过程的公共报告被广泛接受，但关注患者的报告 结果是罕见的。在医院一级公开报告结果的少数程序之一是 经皮冠状动脉介入治疗（PCI）;纽约州（NY）和马萨诸塞州（MA）都已经制定了 全州范围内的死亡率报告。公开报道仍有争议：支持者 我相信它会改善病人的预后，而批评者认为它可能会导致医生避免 为他们认为有高风险的患者提供不良结局的程序，包括高风险 患者和少数民族。然而，缺乏经验数据。没有研究表明， 我们的知识，检查公开报告与非公开报告国家的PCI死亡率趋势，以及 关于公共报告对获得保健的影响的调查有限。我们建议使用医疗保险数据 评估公开报告对纽约接受PCI患者结局和病例选择的影响， MA.我们还建议对导管插入实验室的负责人进行调查，以确定公开报道是否 引导他们采取质量改进活动。我们的具体目标是：确定公共报告是否 与对照州相比，纽约州和马萨诸塞州的PCI死亡率降低; 确定急性心肌梗死高危患者在采用PCI后是否更少接受PCI， 与对照州相比，纽约州和马萨诸塞州的公开报告;并评估心脏病主任是否 有公开报告的州的导管插入实验室报告通过了具体的质量改进措施 努力我们认为，这项工作有可能改变目前的思维和政策。绝大多数 各州尚未采用PCI结果报告系统。如果我们证明公开报道导致了 降低死亡率，而不减少对高危患者的访问，我们的工作将促进使用公共 报告作为质量改进工具。如果我们对死亡率没有影响，或者对获取的有害影响， 我们可能会促进一个更谨慎的评估，以确定在哪里最好地使用和/或采用公共报告， 保障重症患者和少数民族患者获得服务的政策。最后，如果我们发现导管插入术 实验室正在着手进行重大的质量改进活动，以回应公众的报告，我们将 向考虑在其州或社区采用公开报告的领导人提供重要支持。

Project Abstract Candidate: My career goal is to be an independent researcher in quality of care and cardiovascular disease. To this end, I have been lucky to work with tremendous research mentors since medical school, and hope to continue doing so via the Patient-Oriented Research Career Development Award. I completed original research as well as formal research training at the Duke Clinical Research Institute during medical school and residency; most recently, I have served as a clinical fellow in cardiovascular medicine at Brigham and Women's Hospital (BWH), completed my Masters in Public Health in the concentration of Clinical Effectiveness at the Harvard School of Public Health (HSPH), and now serve as a research fellow in the Division of Cardiovascular Medicine at BWH as well as the Department of Health Policy and Management at HSPH. My broad research interests are in understanding the factors that underlie the wide variation in quality and outcomes of care for cardiovascular disease that we see across the country, and the impact of policy-based quality improvement efforts on clinical quality and patient outcomes. Public reporting is one particular area of interest; public reporting has been seen by policy makers as a potentially potent tool to improve transparency and drive improvements in care. With the increased emphasis being placed on both costs and quality that has been driven, in part, by the recently passed Accountable Care Act, there is broad consensus that public reporting efforts will continue to expand, and thus this is an area in which I am especially interested. Environment: My proposed career development program would occur in three settings. The first is HSPH; one specific new skill that this project would require is qualitative research, including interviews and surveys. This is a critical skill for health services research, and I plan to take additional courses at HSPH and seek specific mentorship from colleagues and faculty who have expertise in these areas. The second setting is the Department of Health Policy and Management at HSPH. My primary mentor, Dr. Jha, and co-mentor, Dr. Epstein, both have their primary faculty appointments in this department, and both are nationally-recognized leaders in measuring quality of care and disparities in care; they both have significant experience as mentors and are dedicated to helping me achieve my career goals through mentoring, advising, and research collaboration. The third setting, the Division of Cardiovascular Medicine at BWH, is where my co-mentor Dr. Resnic has his primary appointment. Dr. Resnic has worked closely with the Massachusetts Department of Public Health on their current public reporting efforts, and thus has significant knowledge of this topic. Involvement with Division activities will allow me to keep current not only on salient advances in the treatment of cardiovascular disease via a host of clinical conferences and research conferences, but would also ensure that I continue to develop relationships that could lead to fruitful collaborations in the future. Research: While public reporting focusing on processes of care is widely accepted, reports focusing on patient outcomes are rare. One of the few procedures for which outcomes are publicly reported at the hospital level is percutaneous coronary intervention (PCI); both New York State (NY) and Massachusetts (MA) have instituted statewide reporting of mortality rates for this procedure. Public reporting remains controversial: proponents believe it leads to improvement in patient outcomes, while critics argue that it may lead physicians to avoid offering procedures to patients whom they perceive to be at high risk for poor outcomes, including high-risk patients and racial and ethnic minorities. However, empirical data is lacking. There have been no studies, to our knowledge, examining trends in PCI mortality in public reporting versus non-public reporting states, and only limited investigation of the impact of public reporting on access to care. We propose to use Medicare data to assess the impact of public reporting on outcomes and case selection for patients undergoing PCI in NY and MA. We also propose to survey directors of catheterization laboratories to determine whether public reporting led them to adopt quality improvement activities. Our specific aims are: to determine whether public reporting for PCI was associated with reductions in mortality for PCI in NY and MA compared to control states; to determine whether high risk patients with acute myocardial infarction had less access to PCI after adoption of public reporting in NY and MA compared to control states; and to assess whether directors of cardiac catheterization laboratories in states with public reporting report the adoption of specific quality improvement efforts. We believe that this work has the potential to shift current thinking and policy. The large majority of states have not adopted outcome reporting systems for PCI. If we demonstrate that public reporting led to decreases in mortality with no reduction in access for high-risk patients, our work will promote the use of public reporting as a quality improvement tool. If we show no impact on mortality, or a deleterious impact on access, we will likely catalyze a more prudent assessment of where public reporting is best employed, and/or adoption of policies that safeguard access for severely ill and minority patients. Finally, if we find that catheterization laboratories are embarking on significant quality improvement activities in response to public reporting, we will give important support to leaders contemplating the adoption of public reporting in their states or communities.