Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan.
Med Care. 2011 Dec;49(12):1054-61. doi: 10.1097/MLR.0b013e318235382b.
The impact of cuts in reimbursement, such as the Balanced Budget Act in the United States or global budgeting, on the quality of patient care is an important issue in health-care reform. Limited information is available regarding whether reimbursement cuts are associated with processes and outcomes of acute myocardial infarction (AMI) care.
We used nationwide longitudinal population-based data to examine how 30-day mortality and percutaneous coronary intervention (PCI) use for AMI patients changed in accordance with the degree of financial strain induced by the implementation of hospital global budgeting since July 2002 in Taiwan.
We analyzed all 102,520 AMI patients admitted to general acute care hospitals in Taiwan over the period 1997 to 2008 through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was performed after adjustment for patient, physician, and hospital characteristics to test the association of reimbursement cuts with 30-day mortality and PCI use.
The mean magnitude of payment reduction on overall hospital revenues was highest (10.02%) during the period 2004 to 2005. Large reimbursement cuts were associated with higher adjusted 30-day mortality. There was no statistically significant correlation between reimbursement cuts and PCI use.
The mortality of AMI patients increases under increased financial strain from cuts in reimbursement. Nevertheless, the use of PCI is not affected throughout the study period. Reductions in the quantity or quality of services with a negative contribution margin or high cost, such as nurse staffing, may explain the association between reimbursement cuts and AMI outcome.
在美国的《平衡预算法案》或全球预算等报销削减对患者护理质量的影响是医疗改革中的一个重要问题。关于报销削减是否与急性心肌梗死（AMI）护理的过程和结果有关，可获得的信息有限。
我们使用全国性纵向基于人群的数据分析了自 2002 年 7 月以来，由于台湾地区医院实行全球预算制而导致的财务压力程度，对 AMI 患者 30 天死亡率和经皮冠状动脉介入治疗（PCI）使用率的影响。
我们分析了 1997 年至 2008 年期间在台湾普通急症护理医院住院的所有 102520 例 AMI 患者，使用台湾全民健康保险研究数据库。在调整了患者、医生和医院特征后，进行多层次逻辑回归分析，以检验报销削减与 30 天死亡率和 PCI 使用之间的关联。
2004 年至 2005 年期间，整体医院收入减少的平均幅度最大（10.02%）。大的报销削减与调整后的 30 天死亡率升高有关。报销削减与 PCI 使用之间没有统计学上的显著相关性。
在报销削减导致财务压力增加的情况下，AMI 患者的死亡率增加。然而，在整个研究期间，PCI 的使用不受影响。可能是由于贡献边际低或成本高的服务，如护士人力减少或质量下降，导致了报销削减与 AMI 结果之间的关联。
