Impact of Health Deductible Health Plans on the Evaluation, Treatment, and Outcomes for Acute Coronary Syndrome

项目摘要 这一K23奖项将使候选人周世川，医学博士，公共卫生硕士，SM成为一名独立的 内科医生-科学家关注自付费用对急性胸部疾病的护理利用和预后的影响 疼痛和心血管护理。胸痛是急诊科最常见的原因之一。 评价，每年访问量超过700万次。急诊科探访确保及时识别和治疗急性 心肌梗死(AMI)或急性冠状动脉综合征(ACS)。然而，护理的财务影响 在过去20年里，随着高免赔额健康计划(HDHP)的增长，这一趋势不断升级。到2020年， 拥有雇主担保保险的美国员工中，近六成的免赔额将达到1,000≥美元。而当 研究已经开始探索HDHP在癌症筛查和慢性病管理方面的作用，几乎没有 研究已经检查了它如何影响急性心血管护理。在一项初步研究中，周博士发现 HDHP登记减少了非特异性胸痛的急诊率，但增加了胸痛入院后的急性心肌梗死 在低收入人群中。在这本K23中，周博士将进一步扩展这项研究，提出3项建议 目标。目标1将在一个大型商业索赔数据库中使用分段生存分析来检查 雇主强制的HDHP登记对急性心肌梗死的预后有负面影响。使用相同的数据库，目标2 将利用患者对每个ED中的ED临床医生的自然随机性来确定HDHP 减少具有较高入院倾向的临床医生的低价值胸痛入院。最后，目标3将 包括患者调查和访谈，以引起胸痛和急性心肌梗死患者对多高的 零花钱影响了他们寻求治疗的决定，感知到的治疗质量，以及随后的经济影响。全 AIMS将进一步专注于面临不成比例的经济压力的低收入患者。周博士提出了一个 全面的职业发展课程，以补充这些目标，包括广泛的说教和 体验式学习。周博士已经组建了一个由公认的专业知识组成的跨学科导师团队 在准实验观察研究、保险福利设计、心血管急症、医疗保健 差异和急诊医学，他们将在这些主题上为他提供密集的指导。这个 拟议的研究和职业发展活动将使周博士能够在 与保险相关的政策、护理的财政负担及其对患者使用和结果的影响 患有急性心血管疾病。这一奖项将使周博士能够过渡到独立的 临床医生-科学家，专注于高自付成本的短期和长期影响及其影响 围绕急性计划外护理越来越多地实施价格透明度和成本讨论 来访。完成拟议的研究将产生强有力的证据，以促进对 患者经济负担的临床影响，指导未来围绕保险费用分担政策的监管，以及 通报急性心血管护理价格透明倡议的实施情况。

PROJECT ABSTRACT This K23 award will enable the candidate, Shih-Chuan Chou, MD, MPH, SM, to become an independent physician-scientist focused on the effect of out-of-pocket costs on care utilization and outcomes of acute chest pain and cardiovascular care. Chest pain is one of the most common reasons for emergency department (ED) evaluation, with over 7 million visits annually. ED visits ensure the timely identification and treatment of acute myocardial infarction (AMI) or acute coronary syndrome (ACS). However, the financial implications of care have escalated over the past two decades with the growth of high deductible health plans (HDHP). By 2020, nearly 6 in 10 US employees with employer-sponsored insurance will have deductibles of ≥$1,000. While research has begun to explore HDHP’s effect on cancer screening and chronic disease management, little research has examined how it affects acute cardiovascular care. In a preliminary study, Dr. Chou found that HDHP enrollment reduced ED visits for non-specific chest pain but increased AMI after chest pain admission among the lower-income population. In this K23, Dr. Chou will further extend this research with 3 proposed aims. Aim 1 will use segmented survival analysis in a large commercial claims database to examine whether employer-mandated HDHP enrollment negatively impacted AMI outcomes. Using the same database, aim 2 will utilize the natural randomization of patients to ED clinicians within each ED to determine whether HDHP reduces low-value chest pain admissions among clinicians with high admitting tendencies. Lastly, aim 3 will include patient surveys and interviews to elicit chest pain and AMI patients’ perspectives on how high out-of- pocket costs affected their decisions to seek care, perceived care quality, and subsequent financial impact. All aims will further focus on low-income patients that face disproportionate financial stress. Dr. Chou proposed a comprehensive career development curriculum to complement these aims, consisting of extensive didactic and experiential learning. Dr. Chou has assembled an interdisciplinary team of mentors with recognized expertise in quasi-experimental observational studies, insurance benefit design, cardiovascular emergencies, health care disparities, and emergency medicine, who will provide him with intensive mentorship in these topics. The proposed research and career development activities will allow Dr. Chou to establish his expertise in insurance-related policies, the financial burden of care, and their impact on the use and outcomes of patients with acute cardiovascular conditions. This award will enable Dr. Chou to transition into an independent clinician-scientist focusing on the short- and long-term impact of high out-of-pocket costs and the implications around the growing implementation of price transparency and cost discussions for acute unscheduled care visits. Completing the proposed research will generate robust evidence to advance the understanding of the clinical impact of patient financial burden, guide future regulations around insurance cost-sharing policies, and inform the implementation of price transparency initiatives in acute cardiovascular care.