Implications of cardiovascular technology diffusion among Medicare beneficiaries

描述(由申请人提供)：美国食品和药物管理局最近批准了药物洗脱冠状动脉支架(2003年)和颈动脉支架(2004年)，以及医疗保险和医疗补助服务中心(CMS)扩大了植入式心脏复律除颤器的覆盖范围(2003年和2005年)，使数十万老年联邦医疗保险受益者成为新的有资格接受昂贵心血管技术的人。这些监管决定需要政府每年在老年人心血管保健方面额外支出数十亿美元。由于新技术是医疗成本的主要驱动力，政策制定者一直试图塑造新技术进入医疗市场的过程。政策，如医疗保险的新的“证据确定的覆盖范围”，以及将一些技术的覆盖范围限制在“高质量”的医院，就是两个这样的例子。然而，在确保有效利用保健技术(以最低成本最大化健康结果)和促进保健公平(为历史上处于不利地位的联邦医疗保险受益人提供同等机会获得有希望的技术)之间存在内在的矛盾。为了探索这种紧张的两端，我们将分析2001-2006年的全国联邦医疗保险索赔数据，以追求以下目标：(1)我们将描述美国各医院和小地区在早期采用药物洗脱冠状动脉支架、用于初级预防心脏性猝死的植入型心律转复除颤器和颈动脉支架方面的差异，并确定这种差异是否与CMS管理技术覆盖范围的政策差异、采用技术的财务激励、医院的结构/财务特征以及当地卫生系统的特征有关。(2)我们将确定早期采用这些技术的差异是否对这些疗法在医院或拥有大量种族和少数族裔和/或社会经济地位较低人口的小地理地区的可获得性产生重大影响。(3)我们将估计，与那些被确定为缓慢或持续低采用者相比，在医院和被确定为早期采用者的医院和地区进行技术传播的第一年，临床结果的改善和成本的同时增加。与公共健康相关：源源不断的有效但昂贵的新心血管设备不断地和频繁地进入医疗市场。因此，公众对优化为所有老年美国人提供有益的新技术的过程，无论他们的种族、位置或卫生系统特征，以及促进这些新技术在整个系统内的有效采用，以便使这些疗法最大限度地为所有临床合适的受益者提供健康福利的机会，同时将日益有限的卫生保健资源的使用降至最低，都具有强烈的兴趣。

DESCRIPTION (provided by applicant): Recent Food and Drug Administration approvals of drug-eluting coronary stents (2003) and carotid arterial stents (2004), as well as the expansions of coverage indications for implantable cardioverter- defibrillators (2003 and 2005) by the Centers for Medicare and Medicaid Services (CMS), have made hundreds of thousands of elderly Medicare beneficiaries newly eligible recipients of expensive cardiovascular technologies. These regulatory decisions entail additional expenditures of billions of dollars annually by the government on cardiovascular health care for the elderly. As new technologies are the leading driver of health care costs, policymakers have been attemping to shape the process by which new technologies diffuse into the health care marketplace. Policies such as Medicare's new "Coverage with Evidence Determination," as well as limiting coverage of some technologies to hospitals that are "high quality," are two such examples. However, there is an inherent tension between ensuring that health care technologies are used efficiently (maximizing health outcomes at minimum cost), and promoting health care equity (providing equivalent access to promising technologies to historically disadvantaged Medicare beneficiaries). To explore both ends of this tension, we will analyze national Medicare claims data from 2001-2006 in pursuit of the following goals: (1) We will describe differences across U.S. hospitals and small geographic areas in the patterns of early adoption of drug-eluting coronary stents, implantable cardioverter- defibrillators for primary prevention of sudden cardiac death, and carotid arterial stents, and determine if this variation was associated with differences in CMS policies governing technology coverage, financial incentives for technology adoption, structural/financial characteristics of hospitals, and local health system characteristics. (2) We will determine if variation in early adoption of these technologies had significant impact on the availability of these therapies in hospitals or small geographic areas with large racial and ethnic minority and/or low socioeconomic status populations. (3) We will estimate improvements in clinical outcomes and concurrent increases in costs during the first years of technology diffusion in hospitals and localities identified as early adopters, compared to those identified as slow or persistently low adopters. Relevance to public health: An unending stream of effective-but-expensive new cardiovascular devices continually and frequently enters the medical marketplace. Thus, the public has strong interests in both optimizing the process by which beneficial new technologies become available to all elderly Americans regardless of their race, location, or health system characteristics, as well as promoting efficient system-wide adoption of these new technologies so that these therapies maximize the opportunity for health benefits for all clinically-appropriate beneficiaries while minimizing the use of increasingly limited health care resources.