Identifying effective strategies used by Medicare Accountable Care Organizations to improve outcomes for patients with heart failure: A mixed-methods study

项目摘要 超过570万美国成年人患有心力衰竭（HF），预计患病率将增加 在接下来的20年里增长了46%。HF护理的总成本每年超过300亿美元。HF患者在 不良结局的高风险，包括住院、残疾和死亡。一种新的干预措施， 成本和提高医疗保险受益人的护理质量是实施责任护理 组织（ACO）。ACO由医生和其他医疗保健实体组成， 自愿为患者提供协调一致的高质量护理。如果这导致成本降低，ACO 与医疗保险计划分享储蓄。同时要求ACO满足质量指标， 确保成本降低是人口健康改善的结果（而不是否认 为受益人服务）。截至2017年，医疗保险共享储蓄计划（MSSP），一个大型医疗保险计划， 该计划为ACO的形成提供激励，包括全国900多万名医疗保险患者 全国有400多个助理指挥官初步数据表明，在ACO之间， HF患者。我们假设这种变化与组织和交付的差异有关， 在ACOs中护理。例如，护理管理的使用或实施可能因ACO而异， 结果的差异。 我们的长期目标是确定有效的输送系统干预措施，以改善健康， HF患者的结局。本建议的目的是确定战略和背景因素 这使得一些ACO能够实现更好的风险标准化结果，包括：降低急性入院率 （RSAAR），更少的专业护理天数（RSSNF）和更低的死亡率（RSMRs）。目标1将 检查ACO的结果，并确定结果随时间变化的轨迹模式。每个ACO将 根据风险标准化结果的趋势，为患者分配一个“表型”。然后我们将检查 表型与ACO特征之间的关联。在目标2中，我们将进行定性访谈， 从高性能和低性能表型中提取的ACO样本，目的是完善我们的理解 让一些ACO取得更好成果的因素和策略。就目标3而言，我们会进行一项 调查所有剩余的MSSP ACO（目标2中未抽样的），以检查识别出的 使用多项式回归的策略和结果。这项工作的结果将告知卫生系统 领导者和政策制定者在ACO内实施护理管理策略， 更广泛地应用于MSSP。这些活动高度响应国家心肺气血 研究所的战略目标和具体目标，特别是目标6，其目的是“优化翻译， 临床和实施研究，以改善健康和减少疾病。”

PROJECT SUMMARY More than 5.7 million American adults experience heart failure (HF), and prevalence is expected to increase by 46% in the next two decades. Total costs of HF care exceed $30 billion annually. Patients with HF are at high risk for poor outcomes, including hospitalization, disability, and death. A novel intervention for lowering costs and improving quality of care for Medicare beneficiaries is the implementation of Accountable Care Organizations (ACOs). ACOs consist of groups of doctors and other health care entities that come together voluntarily to provide their patients with coordinated, high-quality care. If this results in lower costs, the ACO shares the savings with the Medicare program. ACOs are simultaneously required to meet quality metrics to ensure that cost reductions are the result of improvements in population health (and not the result of denying services to beneficiaries). As of 2017, the Medicare Shared Savings Program (MSSP), a large Medicare program that provides incentives for ACO formation, included more than 9 million Medicare patients across more than 400 ACOs nationwide. Preliminary data suggests there is variation across ACOs in outcomes for patients with HF. We hypothesize that this variation is related to differences in the organization and delivery of care within ACOs. For example, use or implementation of care management may vary across ACOs, leading to differences in outcomes. Our long-term goal is to identify effective delivery-system interventions that improve the health and outcomes of patients with HF. The objective of this proposal is to identify the strategies and contextual factors that lead some ACOs to achieve better risk-standardized outcomes including: lower acute admission rates (RSAARs), fewer days in skilled nursing care (RSSNFs), and lower mortality rates (RSMRs). Aim 1 will examine outcomes across ACOs and identify patterns in the trajectories of outcomes over time. Each ACO will be assigned a “phenotype” based on trends in risk-standardized outcomes. We will then examine the association between phenotypes with ACO characteristics. In Aim 2, we will conduct qualitative interviews with a sample of ACOs taken from high- and low- performing phenotypes with the goal of refining our understanding of the factors and strategies that allow some ACOs to achieve better outcomes. For Aim 3, we will conduct a survey of all remaining MSSP ACOs (those not sampled in Aim 2) to examine associations between identified strategies and outcomes using multinomial regression. The results of this work will inform health system leaders and policymakers as they implement care management strategies within ACOs and consider changes to the MSSP more broadly. These activities are highly responsive to the National Heart Lung and Blood Institute’s Strategic Goals and Objectives, specifically objective 6, which aims to “optimize translational, clinical, and implementation research to improve health and reduce disease.”