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.

Public Health Relevance

Public reporting has become common despite a lack of clear data on its impact on clinical outcomes or on high-risk patients'access to care. Our study aims to determine whether adoption of public reporting in New York and Massachusetts was associated with reductions in risk-adjusted mortality for percutaneous coronary intervention (PCI) compared to control states, to examine the impact of public reporting on high risk and minority patients'access to PCI, and to determine whether public reporting led to the adoption of specific quality improvement programs in cardiac catheterization laboratories in Massachusetts. This project could have significant public health implications as policymakers seek innovative ways to improve health care quality.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Mentored Patient-Oriented Research Career Development Award (K23)
Project #
5K23HL109177-03
Application #
8508301
Study Section
Special Emphasis Panel (ZHL1-CSR-X (M1))
Program Officer
Fine, Larry
Project Start
2011-08-19
Project End
2016-06-30
Budget Start
2013-07-01
Budget End
2014-06-30
Support Year
3
Fiscal Year
2013
Total Cost
$139,231
Indirect Cost
$10,313
Name
Brigham and Women's Hospital
Department
Type
DUNS #
030811269
City
Boston
State
MA
Country
United States
Zip Code
02115
Joynt, Karen E; Orav, E John; Jha, Ashish K (2014) Association between hospital conversions to for-profit status and clinical and economic outcomes. JAMA 312:1644-52
Tsai, Thomas C; Orav, E John; Joynt, Karen E (2014) Disparities in surgical 30-day readmission rates for Medicare beneficiaries by race and site of care. Ann Surg 259:1086-90
Epstein, Arnold M; Joynt, Karen E; Jha, Ashish K et al. (2014) Access to coronary artery bypass graft surgery under pay for performance: evidence from the premier hospital quality incentive demonstration. Circ Cardiovasc Qual Outcomes 7:727-34
Joynt, Karen E; Le, Sidney T; Orav, E John et al. (2014) Compensation of chief executive officers at nonprofit US hospitals. JAMA Intern Med 174:61-7
Chatterjee, Paula; Joynt, Karen E (2014) Do cardiology quality measures actually improve patient outcomes? J Am Heart Assoc 3:e000404
Joynt, Karen E; Orav, E John; Jha, Ashish K (2013) Mortality rates for Medicare beneficiaries admitted to critical access and non-critical access hospitals, 2002-2010. JAMA 309:1379-87
McCrum, Marta L; Joynt, Karen E; Orav, E John et al. (2013) Mortality for publicly reported conditions and overall hospital mortality rates. JAMA Intern Med 173:1351-7
Joynt, Karen E; Jha, Ashish K (2013) Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program. JAMA 309:342-3