Cardiac care in specialty and general hospitals

描述（由申请人提供）：最近出现的心脏专科医院引起了广泛的争议。支持者认为，这类医院提供质量更高、成本更低的医疗服务，而批评者则认为，专科医院“挑选”的是病情较轻、利润更高的患者，而患者的预后却没有明显的改善。先前比较专科心脏医院和综合医院的研究只考察了有限数量的条件和程序，只包括相对较少的专科医院，并且没有考察在同一医疗保健市场中专科医院对综合医院的影响。这些初步研究的结果不一致，一些研究表明专科医院的结果有所改善，而另一些研究表明没有改善。此外，尽管这种方法具有潜在的优势，但这些初步研究完全基于行政数据来源，没有利用临床登记。拟议研究的具体目的是比较在心脏专科医院和竞争性综合医院接受治疗的患者的结果，并检查专科医院对同一市场中综合医院的影响。这项为期四年的研究将包括分析两个行政数据源（国家医疗保险和州级索赔数据）以及两个专有临床注册（胸外科学会国家数据库和国家心血管数据注册）。该研究将通过检查在大量心脏专科医院治疗的患者的结果来解决先前研究的局限性，这些患者包括急性心肌梗死和充血性心力衰竭患者以及接受经皮冠状动脉介入治疗、冠状动脉搭桥手术和瓣膜置换术的患者，使用行政和临床数据。对于每一项诊断，心脏专科医院的死亡率和并发症发生率将与与专科医院处于同一医疗保健市场的竞争性综合医院的死亡率和并发症发生率进行比较。将使用三种互补的方法来最小化选择偏差（层次线性模型、倾向得分和工具变量），并调整重要的患者水平、医院水平和市场水平混杂因素。其他分析将评估新的专科心脏医院对位于同一医疗保健市场的竞争性综合医院的心脏容量和患者结果的影响。总之，这些分析将提供非常需要的信息，由心脏专科医院提供的相对质量护理的决策者，付款人，提供者和患者。

DESCRIPTION (provided by applicant): The recent emergence of specialty cardiac hospitals has generated widespread controversy. Proponents suggest that such hospitals deliver higher quality and lower cost care, while critics contend that specialty lospitals "cherry pick" lower severity and more profitable patients with no demonstrable improvements in patient outcomes. Prior studies comparing specialty cardiac and general hospitals have examined a limited number of conditions and procedures, have included relatively few specialty hospitals, and have not examined the impact of specialty hospitals on general hospitals in the same healthcare markets. The results of these preliminary studies have been inconsistent with some studies demonstrating improved outcomes in specialty hospitals and others demonstrating no improvement. Moreover, these initial studies have been based exclusively upon administrative data sources and have not utilized clinical registries despite the potential advantages of this approach. The specific aims of the proposed research are to compare the outcomes of patients receiving care in specialty cardiac and competing general hospitals and to examine the impact of specialty hospitals on general hospitals in the same markets. This four-year study will involve the analysis two administrative data sources (national Medicare and state-level claims data) supplemented by two proprietary clinical registries (the Society for Thoracic Surgeons National Database and the National Cardiovascular Data Registry). The research will address the limitations of prior studies by examining outcomes of patients treated in a larger number of specialty cardiac hospitals for a broad spectrum of conditions, including patients with acute myocardial infarction and congestive heart failure and patients undergoing percutaneous coronary interventions, coronary artery bypass graft surgery, and valve replacement surgery using both administrative and clinical data. For each diagnosis, mortality and complication rates in specialty cardiac hospitals will be compared with mortality and complication rates in competing general hospitals located within the same healthcare market as the specialty hospitals. Three complementary methods will be used to minimize selection bias (hierarchcial linear models, propensity scores, and instrumental variables) and adjust for important patient-level, hospital-level, and market-level confounders. Additional analyses will assess the impact of new specialty cardiac hospitals on the cardiac volumes and patient outcomes of competing general hospitals located within the same healthcare markets. Together these analyses will provide much needed information on the relative quality of care provided by specialty cardiac hospitals to policy makers, payors, providers and patients.