Effectiveness of Strategies to Improve Outcomes after Hospitalization for Acute Myocardial Infarction in Older Adults

急性心肌梗塞(AMI)一直被列为最昂贵的五种疾病之一 到联邦医疗保险，并一直是几项成本控制措施的目标，包括联邦医疗保险医院 减少再入院人数计划。为了改善急性心肌梗死住院后的预后，支付者实施了 公共报告、财务处罚和替代支付模式，以激励财务假设 风险，如头衔。这些措施没有伴随着循证指南，说明如何 卫生系统可以改善住院后的结果。阻碍这种指导的一个因素是 对可能影响改进策略有效性的患者层面因素的认识不全面 在真实环境中应用的急性心肌梗死后住院结果。值得注意的是，30%的患者因 AMI的年龄是≥75岁。这些患者的生理储备较低，功能障碍较多，包括 那些在认知和体能方面，比年轻的患者。在Silver-AMI研究中，我们招募了3041人 年龄75岁的≥患者因急性心肌梗死在94家医院住院。主要目标是评估以下方面的贡献 改善6个月内死亡风险预测的功能障碍和老年状况 出院。白银-急性心肌梗死研究的前提是出院时的风险预测可以 确定可能从更密集的院后护理中受益的高危患者。银质急性心肌梗死的临床表现 已经证明，功能障碍大大改善了对重要结果的风险预测。我们 在此研究中未获得联邦医疗保险数据，因此无法检查为改进而部署的策略 急性心肌梗死后的预后。这项建议的总体目标是加深我们对以下影响的理解 家庭健康护理(HHC)(目标1)、早期门诊护理(目标2)和医疗保险优势(MA)(目标3) 通过检查它们在功能障碍和疾病严重程度方面的影响来住院。我们会 重点关注对老年患者最重要的结果，包括“家庭天数”(出院后存活的天数 以及其他住院设施)和健康状况，以及与急性心肌梗死后相关的疾病特定结局。我们 将把Silver-AMI研究的数据与联邦医疗保险数据合并，以实现我们的目标。结合这些数据 消息来源将为我们提供独特的机会来核算一系列经过严格评估的协变量 在仅使用管理数据的研究中通常不可用，并用于确定可能受益最大的患者 从出院后的服务。除了考虑大量可测量的混杂因素外，我们还将采用 先进的统计技术，以解决来自未测量的混杂的偏差。我们已经组建了一个团队， 在心血管结果、家庭保健、门诊护理方面的合作和专业知识的跟踪记录 接生、流行病学和生物统计学。这项假设驱动的研究将利用最全面的 一组在急性心肌梗死住院期间收集的关于功能障碍和老年状况的数据， 国家队列，以提供战略，以改善对老年患者重要的结果。

Acute myocardial infarction (AMI) is consistently ranked as one of the top five most expensive conditions billed to Medicare and has been the target of several cost containment measures, including Medicare’s Hospital Readmissions Reduction Program. To improve outcomes after AMI hospitalizations, payers have implemented public reporting, financial penalties, and alternative payment models that incentivize the assumption of financial risk such as capitation. These measures have not been accompanied by evidence-based guidelines on how health systems can improve outcomes after hospitalization. An impediment to such guidance has been an incomplete understanding of patient-level factors that may influence the effectiveness of strategies to improve post-AMI hospitalization outcomes as applied in real-world settings. Notably, 30% of patients hospitalized for AMI are age ≥ 75. These patients have lower physiologic reserve and more functional impairments, including those in cognition and physical capabilities, than younger patients. In the SILVER-AMI study, we enrolled 3041 patients age ≥ 75 hospitalized for AMI at 94 hospitals. The primary objective was to evaluate the contribution of functional impairments and geriatric conditions to improving risk prediction for mortality within 6 months of hospital discharge. The premise of the SILVER-AMI study was that risk prediction at the time of discharge could identify high-risk patients who might benefit from more intensive post-hospital care. Findings from SILVER-AMI have demonstrated that functional impairments substantially improve risk prediction for important outcomes. We did not obtain Medicare data in this study so could not examine strategies being deployed in an effort to improve post-AMI outcomes. The overall objective of this proposal is to refine our understanding of the impacts of home health care (HHC) (Aim 1), early outpatient care (Aim 2), and Medicare Advantage (MA) (Aim 3) after AMI hospitalization by examining their effects in the context of functional impairments and illness severity. We will focus on outcomes of primary importance to older patients, including “home days” (days alive out of the hospital and other inpatient facilities) and health status, as well as disease-specific outcomes of relevance post-AMI. We will merge data from the SILVER-AMI study with Medicare data to achieve our aims. Combining these data sources will afford us the unique opportunity of accounting for an array of rigorously assessed covariates that are not generally available in studies using only administrative data and to identify patients who may benefit most from post-discharge services. In addition to accounting for a rich array of measured confounders, we will employ advanced statistical techniques to address bias from unmeasured confounding. We have assembled a team with a track record of collaboration and expertise in cardiovascular outcomes, home health care, outpatient care delivery, epidemiology, and biostatistics. This hypothesis-driven research will leverage the most comprehensive set of data on functional impairments and geriatric conditions collected during AMI hospitalization on a large, national cohort to inform strategies to improve outcomes of importance to older patients.