Physician-Hospital Concentration and Patient Outcomes

描述(由申请人提供)：医生经常在多家医院执业，这一行为被认为与对基本医院资源的不熟悉和威望有关。尽管越来越多的人认识到护理过程的改进可以带来更好的质量，但人们对这种行为对程序结果的影响知之甚少。这项建议调查了在多家医院执业是否与经皮冠状动脉介入治疗(PCI)后患者结果的差异有关。经皮冠状动脉介入治疗是一种常见的医院手术，它会扩大堵塞的冠状动脉，这种情况会阻止氧气进入心脏，如果不治疗可能会导致心力衰竭。我在这项建议中评估的患者结果包括再入院、死亡率和再次进行PCI。我将使用2001年至2004年期间接受经皮冠状动脉介入治疗的100%按服务收费(FFS)医疗保险受益人的医疗索赔来实证观察这种关系。为了衡量在多家医院执业的行为，我将开发一套指数衡量标准，以衡量一名医生的PCI量在周围医院的集中度。有三种浓度可能很重要：(A)医生在不同医院的PCI浓度，(B)某家医院的 不同医生之间的经皮冠状动脉介入治疗数量，以及(C)医院的经皮冠状动脉介入治疗医生队伍的集中度水平。我将加入联邦医疗保险索赔记录，从美国医学会(AMA)的主文件中获得医生特征，从美国医院协会(AHA)的年度调查中获得医院特征，从区域卫生资源文件(AHRF)中获得地理市场水平的特征。我将使用我从这些附加数据源中合并的特征，从多个维度(医生、医院和地理区域)记录每个建议的集中度指标中的差异。在控制患者、医生、医院和市场特征的同时，我将评估它们与患者预后的关系，如死亡率、再次入院和重复介入治疗。这项研究将改进以前对这种关系进行建模的努力，既扩大了这种关系的概括性，又处理了可能的选择偏差。医生对医院的选择可能会受到医院质量的影响，而研究人员并不能完全观察到这一点。这种未被观察到的质量会影响医院的浓度，以及医院的患者结局。我通过以下方法克服了这个问题：(I)使用任何给定医院的患者预后的外部因素对该医院的医生经皮冠状动脉介入治疗容量份额进行建模，(Ii)预测每家医院的医生经皮冠状动脉介入治疗容量份额，并使用这些预测份额构建医生-医院集中度度量，以及(Iii)对预测的医生-医院集中度与患者结果的关系进行建模。这项建议解决了关于患者安全的一个重要的卫生政策问题，并改进了在日益一体化的医生-医院环境中估计医生-医院集中度水平的方法。

DESCRIPTION (provided by applicant): Physicians often practice in multiple hospitals, a behavior believed to be associated with less familiarity and prestige over essential hospital resources. Little is known about what impact this behavior has on procedural outcomes despite a growing recognition that improvements in process of care can lead to better quality. This proposal investigates if practicing in multiple hospitals is related to variation in patient outcoms following Percutaneous Coronary Intervention (PCI). PCI is a common hospital procedure that widens clogged coronary arteries, a condition that prevents oxygen from getting to the heart and can lead to heart failure if left untreated. The patient outcomes I evaluate in this proposal include readmission, mortality and repeat PCI. I will use medical claims from a 100% sample of Fee-For-Service (FFS) Medicare beneficiaries who received PCI over the period 2001 through 2004 to empirically observe this relationship. In order to measure the behavior of practicing in multiple hospitals, I will develop a set of index measures on how concentrated a physician's PCI volume is across their surrounding hospitals. There are three kinds of concentration that might matter: (a) the physician's concentration of PCI across different hospitals, (b) a given hospital's PCI volume spread across different physicians, and (c) the concentration levels of a hospital's PCI physician workforce. I will join the Medicare claim records to physician characteristics from the American Medical Association's (AMA) Masterfile, hospital characteristics from the American Hospital Association (AHA) Annual Survey, and geographic-market level characteristics from the Area Health Resource File (AHRF). I will document variation in each of the proposed concentration measures in multiple dimensions (among physicians, hospitals, and geographic regions) using the characteristics I incorporate from these additional data sources. I will estimate their association with patient outcomes such as mortality, re-admission and repeat PCI while controlling for patient, physician, hospital, and market characteristics. This research will improve on previous efforts to model this relationship, both expanding its generalizability and dealing with a likely selection bias. The physicians' choice of hospital is likely influenced b the quality of the hospital, which is not entirely observable to the researcher. This unobserved quality influences concentration at a hospital, as well as patient outcomes at a hospital. I overcome this problem by: (i) modeling physician PCI volume share at any given hospital using factors exogenous to patient outcomes at that hospital, (ii) predicting physician PCI volume share at each hospital and constructing physician-hospital concentration measures using these predicted shares, and (iii) modeling the relationship of predicted physician-hospital concentration with patient outcomes. This proposal addresses an important health policy question on patient safety and advances methodologies for estimating levels of physician-hospital concentration in an increasingly integrated physician-hospital landscape.