Hospital strategies to improve outcome performance

描述（由申请人提供）：尽管十年来一直在努力改善急性心肌梗死（AMI）患者的护理，但AMI后患者死亡率在各医院之间仍存在很大差异。2003年，医院经风险调整后的30天死亡率为11%至23%，相差两倍多。 虽然病人的生存是住院治疗的基本目标，但我们对医院与低风险调整后的短期死亡率的区别知之甚少。 大量的医疗保健组织理论认为，医院的结构，流程和内部环境可能会影响医院的运营和财务结果，但是，我们有较少的经验证据，他们对临床结果的影响，如风险调整后的死亡率，特别是在AMI患者。 我们将使用混合方法：1）生成关于医院特定工作（特征为使能结构、护理过程和医院内部环境）的假设，这些假设可能与AMI患者的医院风险调整后30天死亡率相关; 2）确定与AMI患者的医院风险调整后30天死亡率在统计学上相关的医院工作。 这种方法采用定性和定量研究的互补方式来产生，然后测试假设。 我们采用了一个经过验证的，风险调整的死亡率模型和分层广义线性模型来研究医院水平的风险调整死亡率的变化。 该风险调整模型已得到国家质量论坛的认可，并将于2007年作为医疗保险和医疗补助服务中心（CMS）公开报告的质量指标。 缺乏证据说明医院水平的风险调整死亡率的差异是我们目前关于如何改善结局的知识中的一个关键空白。 这项研究将为循证医学提供基础，以提高AMI患者风险调整后30天死亡率的医院绩效。 我们将与CMS、JCAHO、美国心脏病学会（ACC）、美国卫生协会（AHA）、退伍军人管理局（VA）和VHA合作制定传播策略。

DESCRIPTION (PROVIDED BY APPLICANT): Despite a decade of efforts to improve care for patients with acute myocardial infarction (AMI) there remains substantial variation across hospitals in patient mortality rates after AMI. The risk-adjusted 30 day mortality rates of hospitals in 2003 ranged from 11% to 23%, more than a two-fold difference. Although patient survival is a fundamental goal of the hospitalization, we know little about what distinguishes hospitals with lower risk-adjusted short-term mortality rates. A substantial body of health care organizational theory posits that hospital structures, processes, and internal environments may influence hospital operational and financial outcomes; however, we have less empirical evidence concerning their influence on clinical outcomes; such as risk-adjusted mortality rates, especially among patients with AMI. We will use a mixed methods approach to: 1) generate hypotheses regarding hospital-specific efforts (characterized as enabling structures, processes of care, and hospital internal environments) that may be associated with hospital risk-adjusted 30 day mortality rates for patients with AMI; and 2) determine the hospital effort that are statistically associated with hospital risk-adjusted 30 day mortality rates for patients with AMI. This methodology employs qualitative and quantitative research in a complementary fashion to generate and then to test hypotheses. We employ a validated, risk-adjusted mortality model and hierarchical generalized linear models to examine hospital-level variation in risk-adjusted mortality. This risk-adjustment model has been endorsed by the National Quality Forum and slated for use by the Centers for Medicare & Medicaid Services (CMS) as a publicly reported quality indicator in 2007. The lack of evidence about what accounts for hospital-level variation in risk -adjusted mortality rates is a critical gap in our current knowledge about how to improve outcomes. The proposed study will provide the foundation for evidence-based efforts to elevate hospital performance in risk-adjusted 30-day mortality for patients with AMI. We will work on dissemination strategies with CMS, JCAHO, American College of Cardiology (ACC), American Health Association (AHA), the Veteran's Administration (VA), and the VHA.