CAUSESANDCONSEQUENCESOFHEALTHCAREEFFICIENCY:OVERVIEW U.S.healthcarespendingisatanall-timehigh,yetlifeexpectancyisstagnant,raisingconcernsthat projectedspendinggrowthwon?tleadtocommensuratehealthgains.Thisisaproblemespeciallypertinentto olderadults,withahighburdenofillnessandintenseuseofhealthcare.InthisP01renewalapplication,we proposetocontinueourlong-standingworkidentifyingefficiencyandinefficiencyinU.S.healthcareby applyingsophisticatedempiricalmethodstomorethan1billionperson-yearsofhealthdata.Weaddress3 topicsintegraltohealthcaredeliveryefficiency:First,ourexplorationofchallengesinclinicaldecisionmaking isexpectedtoidentifysystematicunderuseofeffectivecareandoveruseofineffectivecare,andprovide evidencewhereclinicaltrialsarelacking.Second,wewillexaminetheroleofthehealthcaredelivery environment?howdopatient-sharingnetworks,paymentmodels,andregulationsaffectpatienthealth?Third, throughourmulti-payerdata,weseektounderstandthelimitationsofpolicyanalysisarisingfromafocuson justMedicareorprivate(commercial)data.Forexample,weseektomeasurehowhighcommercialpayment ratesaffectaccessforMedicareorMedicaidenrollees.Allprojectsaimtomeasureandimprovequalityofcare forolder,vulnerablepopulations,includingpeoplewithAlzheimer?sDiseaseandrelateddementia(ADRD). Wepropose3coresand5projects.CoreAprovidesadministrativesupport,CoreBcoordinatesdata;? andCoreC(Methods)developsnewapproachestonetworkanalysisusedinall5projects.InProject1, ?CorrelatesandConsequencesofMakinganAlzheimer?sDiseaseClinicalDiagnosis,?weusethe100% MedicarefilesandclinicallyrichsurveydatatodocumentvariationinADRDdiagnosis,andtestwhetherearly diagnosisis,onnet,beneficialtopatients.Project2,?TheCausesandConsequencesofRiskyPrescribing,? usesMedicarePartDprescriptiondatatostudyadverseoutcomesassociatedwithindividualdrugsanddrug combinationsincludingopioidanalgesics,benzodiazepines,andsedativehypnotics.Weconsiderforces influencinghigh-riskprescribing,suchasshared-patientnetworksandlegalrestrictions.Project3,?Identifying EfficientHealthCareProviders:EvidencefromHospitalClosuresandRegistryData?usesperipheralvascular disease(PAD)registrydata,andclaimsdata,toestimatetherelativeexpertiseofcommunityhospitals.This projectwillvalidatemethodswithnaturalexperiments(hospitalclosing)andanongoingrandomizedtrial. Project4,?CausesandConsequencesofVariationinPublicandPrivatePaymentRates,?hypothesizesthat highcommercialreimbursementratescannegativelyaffectaccesstocareforMedicareandMedicaidpatients. Finally,Project5,?PhysicianCognition,InpatientAdvance-CarePlanning,andOutcomesforSeriouslyIllOlder Adults,?usesacombinationofobservationalandexperimental(randomized-trial)researchin250community hospitalsacrosstheU.S.toimprovethequalityofinpatientphysiciandecision-making.

Public Health Relevance

WeproposetocontinueandextendtheDartmouthP01?slong-standingworktoidentifyandreduceU.S.health careinefficiency.Usingmorethan1billionperson-yearsofhealthdata,weplantotestforsystematicunderuse ofeffectivecareandoveruseofineffectivecare,andtoprovideevidencewhereclinicaltrialdataarelacking. Our5projectsand3coresleveragenetworkanalysis,detailedsurveydata,naturalexperimentssuchas hospitalclosingsandpriceshifts,andaclinicalintervention,tomeasureandimprovethequalityofcarefor olderadults,withaparticularfocusonpeoplewithAlzheimer?sDiseaseandrelateddementia(ADRD).

Agency
National Institute of Health (NIH)
Institute
National Institute on Aging (NIA)
Type
Research Program Projects (P01)
Project #
5P01AG019783-17
Application #
9693110
Study Section
Special Emphasis Panel (ZAG1)
Program Officer
Bhattacharyya, Partha
Project Start
2001-09-15
Project End
2023-02-28
Budget Start
2019-03-01
Budget End
2020-02-29
Support Year
17
Fiscal Year
2019
Total Cost
Indirect Cost
Name
Dartmouth College
Department
Miscellaneous
Type
Graduate Schools
DUNS #
041027822
City
Hanover
State
NH
Country
United States
Zip Code
03755
Missios, Symeon; Bekelis, Kimon (2018) Association of Hospitalization for Neurosurgical Operations in Magnet Hospitals With Mortality and Length of Stay. Neurosurgery 82:372-377
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Jeffery, Molly Moore; Hooten, W Michael; Hess, Erik P et al. (2018) Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use. Ann Emerg Med 71:326-336.e19
Finkelstein, Amy; Ji, Yunan; Mahoney, Neale et al. (2018) Mandatory Medicare Bundled Payment Program for Lower Extremity Joint Replacement and Discharge to Institutional Postacute Care: Interim Analysis of the First Year of a 5-Year Randomized Trial. JAMA 320:892-900

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