Evaluation of variability in care and outcomes for patients with gastrointestinal bleeding

项目摘要 胃肠道出血（GIB）是美国住院患者住院的主要原因， 包括医院之间患者结果具有明显差异的异质性人群。 在全国范围内，30天死亡率估计为7%;然而，死亡率和再入院率差异很大 跨医院这种变异性表明，通过识别和治疗，有可能改善患者护理和挽救生命。 影响GIB住院后结局的可改变因素。患者相关因素，医院 护理的结构和过程在决定许多其他疾病的结果方面发挥着重要作用， 这些因素对GIB相关结局的影响尚未充分确定。的目的 一项建议是确定和了解GIB患者护理的变化来源，包括患者水平 因素、组织（即结构）和护理过程（例如，内镜和介入放射学 （二）医院之间。我们的中心假设是，可改变的因素影响患者的结果， GIB的住院治疗，其中包括结构特征和护理过程。我们的建议是 建立一个跨医院标准化的患者结局多层次模型，考虑患者因素， 评估医院因素的影响，然后定性地探索额外的护理过程，通过 以下相互关联的具体目标：目标1-为GIB结果制定一个风险标准化模型， 医院使用医疗保险住院病人，门诊病人和药品索赔数据。为了确保普遍性， 临床适用性，将在多付款人、多中心数据库中使用UPenn进行模型验证 包含临床变量的卫生系统数据。目标2 -确定医院因素（结构和 使用上述医疗保险的组合数据集， 美国医院协会年度调查数据。目标3 -探讨促进发展的障碍和促进因素 采用定性分析方法，在患者结局较好和较差的医院中， 方法.这种混合方法的方法将允许全面评估护理变化的驱动因素 治疗消化道出血拟议研究的预期成果是，它将确定重要的 与GIB住院患者结局相关的护理中的可修改因素。这可能导致 质量指标的开发和验证，以改善患者护理。为协助完成 研究和进一步的申请人的学术发展，PI将参加课程，建立在 她的理学硕士，专注于使用聚类和纵向数据的统计方法，数据分析 和定性方法。这一建议具有明确和突出的分工和 机构的支持和经验丰富的教师的特殊指导，具有良好的记录，在 流行病学，卫生服务研究，并指导以前的K奖补助金获得者。这些活动将 允许PI发展成为成功的独立NIH资助的研究者和 GI相关健康服务研究的领导者。

PROJECT SUMMARY Gastrointestinal bleeding (GIB) is a major cause of inpatient hospitalizations in the United States, and comprises a heterogeneous population with appreciable variability in patient outcomes amongst hospitals. Nationally, 30-day mortality rates are estimated at 7%; however, mortality and readmission rates vary widely across hospitals. Such variability suggests the potential to improve patient care and save lives by identifying modifiable factors that influence outcomes after hospitalization with GIB. Patient-related factors, hospital structure and processes of care play major roles in determining outcomes for many other diseases, but the impact of these factors on outcomes related to GIB has not been adequately defined. The objective of this proposal is to identify and understand sources of variation in care for patients with GIB, including patient-level factors, organization (i.e. structure) and processes of care (e.g.. endoscopic and interventional radiology utilization) amongst hospitals. Our central hypothesis is that modifiable factors impact patient outcomes during hospitalizations for GIB, which include both structural characteristics and processes of care. Our proposal is to build a multi-level model of patient outcomes standardized across hospitals, accounting for patient factors and assess the impact of hospital factors, and then qualitatively explore additional processes of care, through the following interrelated specific aims: Aim 1- To develop a risk-standardized model for GIB outcomes across hospitals using Medicare inpatient, outpatient, and pharmaceutical claims data. To ensure generalizability and clinical applicability, model validation will be performed in a multipayer, multicenter database and using UPenn health system data which contains clinical variables. Aim 2 - to identify hospital factors (structures and processes of care) associated with GIB outcomes, using a combined dataset of the aforementioned Medicare data with American Hospital Association Annual Survey data. Aim 3 – to explore barriers and facilitators of processes of care for inpatient GIB among hospitals with better and worse patient outcomes, using qualitative methods. This mixed methods approach will allow for a comprehensive evaluation of drivers of variation in care for gastrointestinal bleeding. The expected outcome for the proposed research is that it will identify important modifiable factors in care associated with patient outcomes for those hospitalized with GIB. This can lead to the development and validation of quality metrics to improve patient care. To facilitate completion of the research and further the academic development of the applicant, the PI will enroll in coursework that builds on her Master of Science by focusing on statistical methods using clustered and longitudinal data, data analytics in confounding, and qualitative methodologies. This proposal has unequivocal and outstanding divisional and institutional support and exceptional mentorship of experienced faculty with a strong track record in epidemiology, health services research, and mentoring prior K-award grant recipients. These activities will allow the PI to develop the skills necessary to become a successful independent NIH-funded investigator and a leader in GI-related health services research.