Kidney Epidemiology and Cost Center, University of Michigan School of Public Health, 315 W. Huron St., Ann Arbor, MI 48103, USA.
Med Care. 2010 Apr;48(4):296-305. doi: 10.1097/MLR.0b013e3181c161ce.
Different types of providers often face differing financial incentives for providing similar types of care. This may have implications for payment systems that target improvements in care requiring multiple types of providers.
The objective of this study was to determine how hospitalization influences the anemia of Medicare patients with chronic renal failure, where anemia is treated under a prospective payment system during hospitalizations and under a fee-for-service system during outpatient renal dialysis.
We examined the effects of time in hospital and reason for hospitalization on levels of anemia among 87,263 Medicare renal dialysis patients with a hospital stay of 3 days or more during 2004. Medicare claims were used to measure changes in hematocrit between the month before and the month after hospital discharge, and to classify admissions with a high risk of anemia. Multilevel models were used to study variation in outcomes across providers.
Longer time in the hospital was associated with worsening anemia. As expected, larger declines in hematocrit occurred following admissions for conditions or procedures with a high risk of anemia. However, we observed a similar effect of time in the hospital for admissions both with and without a high risk of anemia. There were relatively large differences in anemia outcomes across both individual hospitals and physicians.
Hospitalization-related anemia increases the need for care by outpatient renal dialysis providers. Efforts to improve care through payment system design are more likely to be successful if financial incentives are aligned across care settings.
不同类型的提供者在提供类似类型的护理时通常面临不同的财务激励。这可能对旨在改善需要多种类型提供者提供的护理的支付系统产生影响。
本研究的目的是确定住院治疗如何影响慢性肾衰竭的 Medicare 患者的贫血，其中贫血在住院期间根据预付款制度进行治疗，在门诊肾透析期间根据按服务收费制度进行治疗。
我们检查了 2004 年期间住院时间和住院原因对 87263 名 Medicare 肾透析患者贫血水平的影响，这些患者的住院时间为 3 天或以上。使用 Medicare 索赔来衡量出院前一个月和出院后一个月之间的血细胞比容变化，并将高贫血风险的入院归类。使用多水平模型研究了不同提供者之间的结果差异。
住院时间越长，贫血越严重。不出所料，具有高贫血风险的疾病或手术的入院后，血细胞比容下降幅度更大。然而，我们观察到，即使在没有高贫血风险的入院情况下，住院时间也会产生类似的影响。在单个医院和医生之间，贫血结果存在较大差异。
与住院相关的贫血增加了门诊肾透析提供者的护理需求。通过支付系统设计来改善护理的努力，如果在所有护理环境中都能保持财务激励的一致性，那么更有可能取得成功。
