Program in Cardiovascular Healthcare Policy

While the US healthcare system is the most technologically advanced in the world, the system is highly fragmented, inefficient, and grows ever more costly each year. Despite spending twice as much on healthcare as other industrialized countries, the US ranks poorly on important health outcomes and on preventable mortality. Moreover, nearly 50 million Americans are uninsured with another 25 million underinsured. Decades of work on regional variations in healthcare has demonstrated that the care a patient receives is not a function of medical need but is a function of where a patient lives. Further measures are desperately needed to improve value and curtail unsustainable growth in healthcare spending.

Because cardiovascular diseases are highly prevalent and result in a high burden of morbidity and mortality, cardiovascular disease results in enormous direct and indirect healthcare expenditures. Over the past decade, cardiology imaging has grown disproportionately compared to other areas of medicine, and there is widespread belief amongst policy makers that these tests are overused. Lifesaving technological advances such as implantable defibrillators, left ventricular assist devices, and cardiac transplantation come with a staggering price tag. Comparative effectiveness research is required to assure that the highest possible return is gained from the large investment in cardiovascular medicine. Further, research is urgently needed to assess the impact of recent policy interventions under the Affordable Care Act on access, cost, and quality of care.

Variations in use of cardiovascular imaging following heart failure diagnosis. In this NIH-funded pilot study, Dr. Farmer and colleagues make use of rich clinical and financial data from the Dartmouth Atlas of Healthcare and the Cardiovascular Research Network (CVRN) to explore variations in rates of cardiovascular imaging use at the hospital level. The CVRN includes data on more than 11 million patients from 14 geographically diverse health plans nationwide. Subsequent work will assess the medical and non-medical factors driving this variation, and the relationship with several outcomes of care.

Developing a conceptual model of heart failure readmissions.   This Department of Medicine funded pilot study lays the foundation for Dr. Farmer’s planned multicenter NIH proposal.  Despite the tremendous resources allocated to healthcare in the United States, concerns are mounting that existing practice models fail to deliver consistent, high quality, evidence-based, cost effective care, especially for patients with chronic conditions. These gaps in healthcare delivery can contribute to inefficient and ineffective resource utilization, as well as poor patient outcomes. This study will combine qualitative input from clinical experts, patients and caregivers with existing data from the published literature to develop a robust conceptual model of readmissions after heart failure hospitalization.

Impact of medical malpractice risk and financial incentives on cardiovascular testing. Currently under review at the NHLBI, this proposal makes use of malpractice claims data, CVRN data, and the Medicare 5% random sample. This work will examine how malpractice risk and financial incentives interact to jointly influence physician behavior in the rate of utilization of cardiac imaging tests. These interactions are likely to be important. For example, if testing is profitable, both the desire to reduce malpractice risk and the desire to enhance profitability could combine to induce higher testing rates. In contrast, even if testing becomes unprofitable, providers’ desire to reduce malpractice risk could provide a “floor” on testing rates and ensure that clinically valuable tests are ordered. Policy makers considering tort reform or reimbursement changes must assess the joint effects of these two factors. No prior study examines both factors together.