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: 8508301
• 负责人: Karen Ellen Joynt Maddox
• 金额: $ 13.92万
• 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/8508301
• 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质量的独立研究人员。 为此，自从医学院起，我很幸运能够与伟大的研究导师合作，并希望通过以患者为导向的研究职业发展奖继续这样做。我在医学院和居住期间在杜克临床研究所完成了原始研究以及正式的研究培训；最近，我曾在Brigham and Hospital（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）的临床有效性集中完成了我的公共卫生硕士学位，现在是BWH以及HENTH Politive and Health Politive and Management in n hshsph and HESPPH。我广泛的研究兴趣是了解我们在全国范围内看到的心血管疾病质量和护理结果的广泛差异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。公开报告是一个特定的感兴趣领域；政策制定者将公开报告视为提高透明度并推动护理改善的潜在有效工具。由于最近通过的《问责法案》的一部分将重点放在成本和质量上，因此人们普遍认为，公开报告工作将继续扩大，因此这是我特别感兴趣的领域。 环境：我建议的职业发展计划将在三个环境中进行。第一个是HSPH；该项目需要的一项特定新技能是定性研究，包括访谈和调查。 这是卫生服务研究的关键技能，我计划在HSPH上学习其他课程，并向在这些领域具有专业知识的同事和教职员工寻求特定的指导。第二个设置是HSPH的卫生政策和管理部。我的主要导师JHA博士和同事Epstein博士都在该部门任命其主要教师，并且都是全国认可的领导者，以衡量护理和护理差异的质量；他们俩都有重要的导师经验，并致力于通过指导，建议和研究合作来帮助我实现自己的职业目标。第三个环境是BWH的心血管医学部，是我的同事Resnic博士的主要任命。 Resnic博士已与马萨诸塞州公共卫生部紧密合作，以实现目前的公开报告工作，因此对此主题有着重要的了解。 参与分区活动将使我不仅可以通过许多临床会议和研究会议来保持最新的心血管疾病治疗方面的显着进步，而且还可以确保我继续建立可能导致未来富有成果合作的关系。 研究：虽然广泛接受关注护理过程的公开报告被广泛接受，但重点关注患者预后的报告很少。在医院一级公开报告结果的少数程序之一是经皮冠状动脉干预（PCI）；纽约州（纽约州）和马萨诸塞州（马萨诸塞州）都已经在全州范围内报告了该程序的死亡率。公开报告仍然存在争议：支持者认为这会改善患者的结局，而批评家则认为，这可能导致医生避免为他们认为对不良结果的高风险（包括高风险患者以及种族和种族和少数民族）的患者提供程序。但是，缺乏经验数据。据我们所知，没有研究在公开报告与非公共报告状态中研究PCI死亡率的趋势，并且仅对公众报告对获得护理的影响的影响有限。我们建议使用Medicare数据来评估公开报告对纽约和MA中PCI患者的结果和案例选择的影响。我们还建议调查导管实验室的董事，以确定公开报告是否导致他们采用质量改进活动。我们的具体目的是：确定PCI的公开报告是否与纽约和MA的PCI死亡率降低有关；确定与对照状态相比，在纽约和MA采用公开报告后，急性心肌梗塞的高风险患者是否可以使用PCI；并评估公开报告中的州心脏导管实验室董事是否报告采用特定质量改进的工作。我们认为，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的结果报告系统。如果我们证明公开报告导致死亡率下降而没有减少高危患者的访问权限，我们的工作将促进公开报告用作质量改进工具。如果我们对死亡率没有任何影响，或者对进入的有害影响，我们可能会催化更谨慎的评估，以评估公众报告最能使用的公共报告和/或采用保护严重病患者和少数族裔患者的政策。最后，如果我们发现导管实验室正在响应公开报告进行重大质量改进活动，我们将为正在考虑在其州或社区中采用公开报告的领导人提供重要的支持。