The Impact of Public Reporting on Outcomes and Case Selection for PCI

公开报告对 PCI 结果和案例选择的影响

• 批准号: 8165932
• 负责人: Karen Ellen Joynt Maddox
• 金额: $ 13.82万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2011
• 资助国家: 美国
• 起止时间: 2011-08-19 至 2016-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8165932
• 关键词: Acute myocardial infarction; Adopted; Adoption; Appointment; Area; Behavior; Cardiac Catheterization Procedures; Cardiogenic Shock; Cardiovascular Diseases; Cardiovascular system; Caring; Catheterization; Clinical; Clinical Research; Clinical effectiveness; Collaborations; Communities; Consensus; Coronary Artery Bypass; Country; Data; Disincentive; Ensure; Environment; Faculty; Future; Geographic Locations; Goals; Health Policy; Health Services Accessibility; Health Services Research; Healthcare Systems; Hospitals; Individual; Institutes; Interview; Investigation; K-Series Research Career Programs; Knowledge; Laboratories; Lead; Literature; Massachusetts; Measures; Medical Residency; Medicare; Medicine; Mentors; Mentorship; Minority; Minority Groups; New York; Operative Surgical Procedures; Outcome; Patient Selection; Patients; Pattern; Performance; Physicians; Policies; Policy Maker; Procedures; Process; Provider; Public Health; Public Health Schools; Qualitative Research; Quality of Care; Reporting; Research; Research Institute; Research Personnel; Research Training; Risk; Shock; Surveys; System; Thinking; Time; Variant; Woman; Work; base; career; career development; clinical care; clinical conference; cost; experience; health care quality; high risk; improved; innovation; interest; medical schools; mortality; patient oriented research; patient population; patient registry; percutaneous coronary intervention; programs; racial and ethnic; response; skills; symposium; tool; trend

DESCRIPTION (provided by applicant): My career goal is to be an independent researcher in quality of care and cardiovascular disease. To this end, I have been lucky to work with tremendous research mentors since medical school, and hope to continue doing so via the Patient-Oriented Research Career Development Award. I completed original research as well as formal research training at the Duke Clinical Research Institute during medical school and residency; most recently, I have served as a clinical fellow in cardiovascular medicine at Brigham and Women's Hospital (BWH), completed my Masters in Public Health in the concentration of Clinical Effectiveness at the Harvard School of Public Health (HSPH), and now serve as a research fellow in the Division of Cardiovascular Medicine at BWH as well as the Department of Health Policy and Management at HSPH. My broad research interests are in understanding the factors that underlie the wide variation in quality and outcomes of care for cardiovascular disease that we see across the country, and the impact of policy-based quality improvement efforts on clinical quality and patient outcomes. Public reporting is one particular area of interest; public reporting has been seen by policy makers as a potentially potent tool to improve transparency and drive improvements in care. With the increased emphasis being placed on both costs and quality that has been driven, in part, by the recently passed Accountable Care Act, there is broad consensus that public reporting efforts will continue to expand, and thus this is an area in which I am especially interested. Environment: My proposed career development program would occur in three settings. The first is HSPH; one specific new skill that this project would require is qualitative research, including interviews and surveys. This is a critical skill for health services research, and I plan to take additional courses at HSPH and seek specific mentorship from colleagues and faculty who have expertise in these areas. The second setting is the Department of Health Policy and Management at HSPH. My primary mentor, Dr. Jha, and co-mentor, Dr. Epstein, both have their primary faculty appointments in this department, and both are nationally-recognized leaders in measuring quality of care and disparities in care; they both have significant experience as mentors and are dedicated to helping me achieve my career goals through mentoring, advising, and research collaboration. The third setting, the Division of Cardiovascular Medicine at BWH, is where my co-mentor Dr. Resnic has his primary appointment. Dr. Resnic has worked closely with the Massachusetts Department of Public Health on their current public reporting efforts, and thus has significant knowledge of this topic. Involvement with Division activities will allow me to keep current not only on salient advances in the treatment of cardiovascular disease via a host of clinical conferences and research conferences, but would also ensure that I continue to develop relationships that could lead to fruitful collaborations in the future. Research: While public reporting focusing on processes of care is widely accepted, reports focusing on patient outcomes are rare. One of the few procedures for which outcomes are publicly reported at the hospital level is percutaneous coronary intervention (PCI); both New York State (NY) and Massachusetts (MA) have instituted statewide reporting of mortality rates for this procedure. Public reporting remains controversial: proponents believe it leads to improvement in patient outcomes, while critics argue that it may lead physicians to avoid offering procedures to patients whom they perceive to be at high risk for poor outcomes, including high-risk patients and racial and ethnic minorities. However, empirical data is lacking. There have been no studies, to our knowledge, examining trends in PCI mortality in public reporting versus non-public reporting states, and only limited investigation of the impact of public reporting on access to care. We propose to use Medicare data to assess the impact of public reporting on outcomes and case selection for patients undergoing PCI in NY and MA. We also propose to survey directors of catheterization laboratories to determine whether public reporting led them to adopt quality improvement activities. Our specific aims are: to determine whether public reporting for PCI was associated with reductions in mortality for PCI in NY and MA compared to control states; to determine whether high risk patients with acute myocardial infarction had less access to PCI after adoption of public reporting in NY and MA compared to control states; and to assess whether directors of cardiac catheterization laboratories in states with public reporting report the adoption of specific quality improvement efforts. We believe that this work has the potential to shift current thinking and policy. The large majority of states have not adopted outcome reporting systems for PCI. If we demonstrate that public reporting led to decreases in mortality with no reduction in access for high-risk patients, our work will promote the use of public reporting as a quality improvement tool. If we show no impact on mortality, or a deleterious impact on access, we will likely catalyze a more prudent assessment of where public reporting is best employed, and/or adoption of policies that safeguard access for severely ill and minority patients. Finally, if we find that catheterization laboratories are embarking on significant quality improvement activities in response to public reporting, we will give important support to leaders contemplating the adoption of public reporting in their states or communities.

描述（由申请人提供）：我的职业目标是成为护理质量和心血管疾病方面的独立研究员。 为此，我很幸运自医学院以来就与优秀的研究导师一起工作，并希望通过以患者为中心的研究职业发展奖继续这样做。在医学院和住院医师实习期间，我在杜克临床研究所完成了原创研究和正式研究培训；最近，我在布莱根妇女医院 (BWH) 担任心血管医学临床研究员，在哈佛大学公共卫生学院 (HSPH) 完成了公共卫生硕士学位，主修临床有效性，现在担任BWH 心血管医学部以及 HSPH 卫生政策与管理系研究员。我广泛的研究兴趣是了解全国范围内心血管疾病护理质量和结果存在巨大差异的因素，以及基于政策的质量改进工作对临床质量和患者结果的影响。公共报告是一个特别令人感兴趣的领域；政策制定者将公共报告视为提高透明度和推动护理改善的潜在有效工具。最近通过的责任医疗法案在一定程度上推动了人们对成本和质量的日益重视，人们普遍认为公共报告工作将继续扩大，因此这是我正在研究的一个领域特别感兴趣。 环境：我提议的职业发展计划将在三种环境中进行。第一个是HSPH；该项目需要的一项具体新技能是定性研究，包括访谈和调查。 这是卫生服务研究的一项关键技能，我计划在 HSPH 学习额外的课程，并向在这些领域拥有专业知识的同事和教师寻求具体指导。第二个机构是 HSPH 的卫生政策与管理系。我的主要导师 Jha 博士和共同导师 Epstein 博士均在该系担任主要教员，并且在衡量护理质量和护理差异方面都是全国公认的领导者；他们都拥有作为导师的丰富经验，并致力于通过指导、建议和研究合作帮助我实现职业目标。第三个地点是 BWH 的心血管医学科，这是我的搭档 Resnic 博士主要就诊的地方。 Resnic 博士与马萨诸塞州公共卫生部就其当前的公共报告工作密切合作，因此对该主题有丰富的了解。 参与该部门的活动不仅使我能够通过一系列临床会议和研究会议了解心血管疾病治疗方面的显着进展，而且还能确保我继续发展关系，从而在未来实现富有成效的合作。 研究：虽然关注护理过程的公开报告已被广泛接受，但关注患者治疗结果的报告却很少。经皮冠状动脉介入治疗 (PCI) 是医院层面公开报告结果的少数手术之一；纽约州 (NY) 和马萨诸塞州 (MA) 已在全州范围内报告该手术的死亡率。公开报告仍然存在争议：支持者认为这会改善患者的治疗结果，而批评者则认为这可能会导致医生避免向他们认为具有不良结果高风险的患者提供手术，包括高风险患者以及种族和民族患者少数民族。然而，缺乏经验数据。据我们所知，还没有研究调查公开报告与非公开报告国家的 PCI 死亡率趋势，并且仅对公开报告对获得护理的影响进行了有限的调查。我们建议使用 Medicare 数据来评估公开报告对纽约州和马萨诸塞州接受 PCI 患者的结果和病例选择的影响。我们还建议对导管实验室主任进行调查，以确定公开报告是否促使他们采取质量改进活动。我们的具体目标是：确定与对照州相比，纽约州和马萨诸塞州 PCI 的公开报告是否与 PCI 死亡率降低相关；确定纽约州和马萨诸塞州采用公开报告后，与对照州相比，急性心肌梗死高危患者接受 PCI 的机会是否较少；并评估有公开报告的州的心导管实验室主任是否报告了采取的具体质量改进措施。我们相信这项工作有可能改变当前的思维和政策。绝大多数州尚未采用 PCI 结果报告系统。如果我们证明公开报告可以降低死亡率，同时不会减少高危患者的就诊机会，那么我们的工作将促进使用公开报告作为质量改进工具。如果我们没有显示出对死亡率的影响，或对获取服务的有害影响，我们可能会促进对公共报告最适用的地方进行更谨慎的评估，和/或采取保障重病患者和少数族裔患者获取服务的政策。最后，如果我们发现导管实验室正在针对公开报告开展重大质量改进活动，我们将为考虑在其州或社区采用公开报告的领导人提供重要支持。