The Impact of Quality Metrics on Outcomes Among Elderly Heart Failure Patients

质量指标对老年心力衰竭患者预后的影响

• 批准号: 10181108
• 负责人: Lauren Gray Gilstrap
• 金额: $ 14.15万
• 依托单位: DARTMOUTH-HITCHCOCK CLINIC
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-08-25 至 2023-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10181108
• 关键词: Acute; Acute Renal Failure with Renal Papillary Necrosis; Admission activity; Adrenergic beta-Antagonists; Age; Angiotensin II Receptor; Angiotensin-Converting Enzyme Inhibitors; Attention; Cardiology; Caring; Characteristics; Clinical; Clinical Management; Clinical Trials; Clinical assessments; Creatinine; Data; Dimensions; Drug usage; EFRAC; Effectiveness; Elderly; Enrollment; Evaluation; Foundations; Future; Guidelines; Heart failure; Heterogeneity; Hospitalization; Hospitals; Hypotension; Incentives; Incidence; Interview; Knowledge; Link; Measurement; Measures; Medicare; Medicare Part A; Methods; Modeling; Outcome; Patient Care; Patient Preferences; Patients; Performance; Pharmaceutical Preparations; Play; Population; Population Heterogeneity; Potassium; Provider; Quality of Care; Quality of life; Randomized Controlled Trials; Recording of previous events; Registries; Risk; Role; Structure; Symptoms; System; Variant; Work; base; beneficiary; care providers; clinical care; comorbidity; comparative effectiveness; data registry; economic implication; frailty; high risk; hospital readmission; improved; interest; medication safety; mortality; multiple chronic conditions; next generation; older patient; patient population; patient response; payment; personalized approach; preference; programs; randomized trial; research clinical testing; side effect

Project Summary/Abstract 1 Quality of care has become a significant component of provider evaluation and reimbursement. As alternative payment 2 models gain popularity and the new Merit-Based Incentive Payment (MIPS) program rolls out, how quality is defined and 3 measured will become increasingly important for patients, providers and payers. In the field of cardiology, most quality 4 metrics are based on findings from large, randomized trials. While robust, randomized trials can be limited in their 5 generalizability, owing to narrowly defined enrollment criteria and the underrepresentation of certain patient populations. 6 This can result in a mismatch between the population in which a therapy has been proven effective and the population in 7 which quality metrics require it use. This, in turn, can create a system of quality measurement that inadvertently incentives 8 non-evidenced based practice or unfairly penalizing certain providers. An example is the use of neurohormonal therapy in 9 elderly patients with heart failure and reduced ejection fraction (HFrEF). Neurohormonal therapies, which include 10 angiotensin converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARB) and beta-blockers, are the 11 cornerstone of HFrEF therapy and their use now defines quality in HFrEF care. While neurohormonal therapies are 12 undoubtedly beneficial in the vast majority of HFrEF patients, elderly patients ≥75 years old were underrepresented in the 13 landmark studies that evaluated the efficacy and safety of these drugs. Since neurohormonal therapies carry a non-trivial 14 risk of side effects, it is possible that the short term risks of therapy outweigh the longer term benefits in certain elderly 15 patients. At present however, neither clinical guidelines nor quality metrics account for this known heterogeneity among 16 elderly HFrEF beneficiaries. To better understand the impact of neurohormonal therapy on elderly HFrEF patients, 17 determine how best to use neurohormonal therapy in elderly HFrEF patients and more effectively measure quality of care 18 among elderly HFrEF patients, a 3-part analysis using administrative, registry and qualitative data is proposed. The 19 project aims to (1) use Medicare data to determine whether and how the clinical benefits of neurohormonal therapy vary 20 by age; (2) to use the national registry data linked with Medicare data to determine characteristics that predict likelihood 21 to benefit from neurohormonal therapy among elderly HFrEF patients and simulate the effectiveness of a targeted 22 approach to therapy using the identified characteristics; and (3) to use semi-structured patient interviews to determine the 23 aspects of care that define “high quality care” for elderly HFrEF patients. This work has the potential to both improve the 24 quantity of care and the quality of life for elderly HFrEF patients as well as improve our current method of quality 25 measurement in heart failure. First, an assessment of existing variation in outcomes with neurohormonal therapy, by age, 26 will define the scope of the issue and the potential for improvement. Secondly, identification of the patient-level 27 characteristics associated with a high likelihood of benefit (or harm) from neurohormonal therapy among elderly HFrEF 28 patients will enable improved clinical care and the refinement of current quality metrics. Finally, a qualitative assessment 29 of elderly HFrEF patient priorities will lay the foundation for future research to develop the next generation of quality 30 metrics that incorporate patient preferences.

项目概要/摘要 1 护理质量已成为提供者评估和报销的重要组成部分。 2 种模式受到欢迎，新的绩效激励支付 (MIPS) 计划推出，质量如何定义以及 3 测量对于患者、提供者和付款人来说将变得越来越重要 在心脏病学领域，最重要的是质量。 4 个指标基于大型随机试验的结果，但稳健的随机试验可能存在局限性。 5 普遍性，因为入组标准定义狭窄且某些患者群体代表性不足。 6 这可能会导致治疗已被证明有效的人群与实际治疗中的人群之间不匹配。 7 需要使用哪些质量指标，这反过来又会创建一个无意中激励的质量测量系统。 8 未经证实的做法或不公平地惩罚某些提供者的一个例子是神经激素疗法的使用。 9 名患有心力衰竭和射血分数降低 (HFrEF) 的老年患者，其中包括神经激素治疗。 10 种血管紧张素转换酶抑制剂 (ACEi)/血管紧张素 II 受体阻滞剂 (ARB) 和 β 阻滞剂是 11 HFrEF 治疗的基石及其使用现在定义了 HFrEF 护理的质量，而神经激素疗法则是。 12 无疑对绝大多数 HFrEF 患者有益，≥75 岁的老年患者在该研究中代表性不足 13 项具有里程碑意义的研究评估了这些药物的功效和安全性，因为神经激素疗法具有重要意义。 14 副作用的风险，对于某些老年人来说，治疗的短期风险可能超过长期益处 然而，目前，临床和质量指标都没有解释指南之间这种已知的异质性。 16 名老年 HFrEF 受益人 为了更好地了解神经激素治疗对老年 HFrEF 患者的影响， 17 确定如何最好地对老年 HFrEF 患者使用神经激素治疗并更有效地衡量护理质量 18 在老年 HFrEF 患者中，建议使用管理、登记和定性数据进行三部分分析。 19 项目旨在 (1) 使用医疗保险数据来确定神经激素治疗的临床益处是否以及如何变化 20 按年龄；(2) 使用与医疗保险数据相关的国家登记数据来确定预测可能性的特征 21 受益于老年 HFrEF 患者的神经激素治疗，并模拟靶向治疗的有效性 22 使用已确定的特征进行治疗；以及 (3) 使用半结构化患者访谈来确定 定义老年 HFrEF 患者“高质量护理”的 23 个方面这项工作有可能改善老年 HFrEF 患者的护理状况。 24 提高老年 HFrEF 患者的护理数量和生活质量，并改进我们目前的质量方法 25 心力衰竭的测量首先，按年龄对神经激素治疗结果的现有变化进行评估。 26号文件将界定问题的范围和改进的潜力 其次，确定患者级别。 与老年 HFrEF 神经激素治疗获益（或危害）的可能性较高相关的 27 个特征 28 名患者将能够改善临床护理并完善当前的质量指标。最后，进行定性评估。 29 名老年 HFrEF 患者优先事项将为未来研究开发下一代质量奠定基础 30 个包含患者偏好的指标。