Hospital-physician integration and the quality of care: evidence from colorectal cancer

项目总结/摘要： 美国的医疗保健系统正在经历一个实质性的整合时期。医院 购买许多医生的做法和一半的医生现在受雇于医院 或综合输送系统。虽然纵向一体化（例如，合并医院， 医生）可以通过护理协调提高质量，也可以降低质量或 增加不必要的使用和支出，量化这些影响的证据有限。 我们的长期目标是了解提供者整合在护理质量和 人口健康。我们的目的是检查结肠镜检查在GI实践中的使用， 说明性情景，以评估医院专家整合对质量的影响， 保健、健康结果和资源使用。我们的具体目标涉及以下问题： (Aim 1：质量）审查地理标志做法所有权地位变化的影响， 医生和实践的结肠镜检查质量测量为：a）程序质量 （息肉切除率、不完全率和并发症发生率）B）患者管理 （筛查结肠镜检查率、随访和监测间隔的适当性）和c） 健康结果测量（间隔癌症发病率）。(Aim 2：资源使用） GI实践的所有权状态变化与CRC资源使用之间的关联， 支出.我们将利用一个自然的实验，其中医疗保险报销差异 医院门诊部和医生的做法之间创造了一个强大的财政 鼓励医院获得实践。我们将使用因果推理方法，如 逆概率加权和工具变量使用状态级变化， 反垄断执法努力调整供应商之间的差异。我们的贡献是 意义重大，因为这将是首次评估医院与医院之间整合的效果， 护理质量专家，目前证据有限的领域。我们的研究还可以 通过检查重要的供应商水平变化，为临床文献做出贡献。 结肠镜检查质量指标，这是癌症结果的预测因子，但目前 大量不为人知的变异。这项研究是创新的，因为它使用 来自全国代表性人口的数据与流行病学信息相关联， 偏差和提高概括性;通过关注同质的 临床领域;并采用准实验设计来解决潜在的混杂因素， 提出强有力的因果关系主张。

PROJECT SUMMARY/ABSTRACT: The U.S. health care system is undergoing a period of substantial consolidation. Hospitals are purchasing many physician practices and half of all physicians are now employed by hospitals or integrated delivery systems. Although vertical integration (e.g., consolidation of hospitals and physicians) could improve quality through care coordination, it could also reduce quality or increase unnecessary use and spending, and the evidence quantifying these effects is limited. Our long-term goal is to understand the role of provider consolidation in care quality and population health. Our objective is to examine colonoscopy use among GI practices as an illustrative scenario to evaluate the impact of hospital-specialist consolidation on the quality of care, health outcomes, and resource use. Our specific aims address the following questions: (Aim 1: Quality) To examine the impact of change in ownership status of GI practices and the colonoscopy quality of physicians and practices measured as: a) procedure quality (polypectomy rates, incompletion rates, and complication rates) b) patient management (screening colonoscopy rate, appropriateness of follow-up and surveillance intervals) and c) health outcome measures (interval cancer incidence). (Aim 2: Resource Use) To examine the association between the change in ownership status of GI practices and CRC resource use and spending. We will exploit a natural experiment in which Medicare reimbursement differences between hospital outpatient departments and physician practices created a strong financial incentive for hospitals to acquire practices. We will use causal inference methods such as inverse probability weighting and instrumental variables using state-level variations in the antitrust enforcement efforts to adjust for the differences among providers. Our contribution is significant since it will be the first evaluation of the effect of consolidation between hospitals and specialists on the quality of care, the area with currently limited evidence. Our study can also contribute to the clinical literature by examining the provider-level variation in important colonoscopy quality measures, which are predictors of cancer outcomes but currently have large amount of poorly understood variations. The proposed study is innovative because it uses data from nationally representative population linked to epidemiologic information to reduce biases and improve generalizability; uses finer measure of quality by focusing on a homogenous clinical area; and adapts a quasi-experimental design to address potential confounders and make strong causal claims.