Plogman P L, Pine M, Reed D C, Byrwa K J, Berman J I
Anthem Blue Cross and Blue Shield, Mason, OH, USA.
Am J Manag Care. 1998 Dec;4(12):1679-86.
To describe a managed care organization's efforts to improve value for its members by forming a coronary services network (CSN).
To identify high-quality facilities for its CSN, Anthem Blue Cross and Blue Shield reviewed claims data and clinical data from hospitals that met its general quality standards. An external firm measured and risk-adjusted applicant hospitals' mortality rates. Hospitals that demonstrated superior performance were eligible to join the CSN. In 1996, 2 years after the CSN was formed, clinical outcomes of participants and new applicants were analyzed again by the same external firm.
Data on more than 10,000 consecutive (all-payer) inpatients discharged after coronary bypass surgery in 1993 were collected from 16 applicant hospitals using a uniform format and data definitions. This analysis was expanded to 23 participating and applicant hospitals that discharged more than 13,000 patients who underwent either bypass surgery or coronary revascularization in 1995. We compared risk-adjusted routine length of stay (a measure of efficiency), mortality rates, and adverse outcome rates between CSN and non-CSN facilities.
From 1993 to 1995, overall length of stay in the network decreased by 20%, from 12.3 to 9.8 days (P < or = 0.01) and severity-adjusted mortality rates decreased by 7.3%, from 2.9% to 2.7%. Initially, facilities outside the network had comparable efficiency but much higher mortality. However, they improved so much in both measures that their severity-adjusted mortality rate for bypass surgery in 1995 was no more than 10% higher than that of CSN hospitals.
The creation of a statewide CSN that emphasized and improved the level of performance among providers ultimately benefited the carrier's managed care members. The desirability of participation was evidenced by an increase in the number of applicant hospitals over the 2 years. This may have stimulated quality improvement among competing providers in the region and among CSN facilities themselves.
描述一家管理式医疗组织通过组建冠状动脉服务网络（CSN）来提高其成员所获价值的努力。
为确定其CSN的高质量设施，Anthem蓝十字蓝盾公司审查了符合其一般质量标准的医院的索赔数据和临床数据。一家外部公司对申请加入的医院的死亡率进行了测量和风险调整。表现卓越的医院有资格加入CSN。1996年，即CSN组建两年后，同一家外部公司再次分析了参与者和新申请者的临床结果。
1993年冠状动脉搭桥手术后连续出院的10000多名（所有付费方）住院患者的数据，采用统一格式和数据定义，从16家申请加入的医院收集。该分析扩展至23家参与医院和申请加入的医院，这些医院在1995年共收治了13000多名接受搭桥手术或冠状动脉血运重建的患者。我们比较了CSN设施和非CSN设施之间经风险调整的常规住院时间（效率指标）、死亡率和不良结局发生率。
从1993年到1995年，网络内的总体住院时间减少了20%，从12.3天降至9.8天（P≤0.01），严重程度调整后的死亡率下降了7.3%，从2.9%降至2.7%。最初，网络外的设施效率相当，但死亡率高得多。然而，它们在这两项指标上都有很大改善，以至于其1995年搭桥手术的严重程度调整后的死亡率比CSN医院高不超过10%。
创建一个强调并提高医疗服务提供者绩效水平的全州范围的CSN最终使该保险公司的管理式医疗成员受益。申请加入的医院数量在两年内有所增加，这证明了参与的意愿。这可能刺激了该地区竞争的医疗服务提供者以及CSN设施自身的质量改进。
