Kahn K L, Rogers W H, Rubenstein L V, Sherwood M J, Reinisch E J, Keeler E B, Draper D, Kosecoff J, Brook R H
Health Program, RAND Corp., Santa Monica, CA 90406-2138.
JAMA. 1990 Oct 17;264(15):1969-73.
We developed explicit process criteria and scales for Medicare patients hospitalized with congestive heart failure, myocardial infarction, pneumonia, cerebrovascular accident, and hip fracture. We applied the process scales to a nationally representative sample of 14,012 patients hospitalized before and after the implementation of the diagnosis related group-based prospective payment system. For the four medical diseases, a better process of care resulted in lower mortality rates 30 days after admission. Patients in the upper quartile of process scores had a 30-day mortality rate 5% lower than that of patients in the lower quartile. The process of care improved after the introduction of the prospective payment system; eg, better nursing care after the introduction of the prospective payment system was associated with an expected decrease in 30-day mortality rates in pneumonia patients of 0.8 percentage points, and better physician cognitive performance was associated with an expected decrease in 30-day mortality rates of 0.4 percentage points. Overall, process improvements across all four medical conditions were associated with a 1 percentage point reduction in 30-day mortality rates after the introduction of the prospective payment system.
我们为因充血性心力衰竭、心肌梗死、肺炎、脑血管意外和髋部骨折住院的医疗保险患者制定了明确的流程标准和量表。我们将这些流程量表应用于在基于诊断相关组的前瞻性支付系统实施前后住院的14012名具有全国代表性的患者样本。对于这四种疾病，更好的护理流程导致入院后30天的死亡率降低。流程评分处于上四分位数的患者30天死亡率比处于下四分位数的患者低5%。引入前瞻性支付系统后护理流程得到改善；例如，引入前瞻性支付系统后更好的护理与肺炎患者30天死亡率预期降低0.8个百分点相关，更好的医生认知表现与30天死亡率预期降低0.4个百分点相关。总体而言，在引入前瞻性支付系统后，所有四种疾病的流程改善与30天死亡率降低1个百分点相关。
