主要绩效薪酬对患者结局的长期影响。

The long-term effect of premier pay for performance on patient outcomes.

机构信息

Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115, USA.

出版信息

N Engl J Med. 2012 Apr 26;366(17):1606-15. doi: 10.1056/NEJMsa1112351. Epub 2012 Mar 28.

DOI:10.1056/NEJMsa1112351

PMID:22455751

Abstract

BACKGROUND

Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes.

METHODS

We used Medicare data to compare outcomes between the 252 hospitals participating in the Premier HQID and 3363 control hospitals participating in public reporting alone. We examined 30-day mortality among more than 6 million patients who had acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary-artery bypass grafting (CABG) between 2003 and 2009.

RESULTS

At baseline, the composite 30-day mortality was similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; difference, -0.07 percentage points; 95% confidence interval [CI], -0.40 to 0.26). The rates of decline in mortality per quarter at the two types of hospitals were also similar (0.04% and 0.04%, respectively; difference, -0.01 percentage points; 95% CI, -0.02 to 0.01), and mortality remained similar after 6 years under the pay-for-performance system (11.82% for Premier hospitals and 11.74% for non-Premier hospitals; difference, 0.08 percentage points; 95% CI, -0.30 to 0.46). We found that the effects of pay for performance on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and among conditions not linked to incentives (congestive heart failure and pneumonia) (P=0.36 for interaction). Among hospitals that were poor performers at baseline, mortality was similar in the two groups of hospitals at the start of the study (15.12% and 14.73%; difference, 0.39 percentage points; 95% CI, -0.36 to 1.15), with similar rates of improvement per quarter (0.10% and 0.07%; difference, -0.03 percentage points; 95% CI, -0.08 to 0.02) and similar mortality rates at the end of the study (13.37% and 13.21%; difference, 0.15 percentage points; 95% CI, -0.70 to 1.01).

CONCLUSIONS

We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest.

摘要

背景

按绩效付费已成为改善医疗保健的核心策略。我们评估了医疗保险卓越医院质量激励计划（Premier HQID）对患者预后的长期影响。

方法

我们使用医疗保险数据比较了 2003 年至 2009 年间 600 多万例急性心肌梗死、充血性心力衰竭或肺炎患者或接受冠状动脉旁路移植术（CABG）患者在参与 Premier HQID 的 252 家医院和仅参与公开报告的 3363 家对照医院之间的结局。

结果

基线时，Premier 和非 Premier 医院的复合 30 天死亡率相似（分别为 12.33%和 12.40%；差值，-0.07 个百分点；95%置信区间[CI]，-0.40 至 0.26）。两种类型医院每季度死亡率下降的速度也相似（分别为 0.04%和 0.04%；差值，-0.01 个百分点；95%CI，-0.02 至 0.01），在支付绩效薪酬系统下运行 6 年后，死亡率仍然相似（Premier 医院为 11.82%，非 Premier 医院为 11.74%；差值，0.08 个百分点；95%CI，-0.30 至 0.46）。我们发现，对于与激励措施明确相关的结局（急性心肌梗死和 CABG）和与激励措施不相关的结局（充血性心力衰竭和肺炎），绩效薪酬对死亡率的影响没有显著差异（交互作用 P=0.36）。在基线时表现不佳的医院中，两组医院在研究开始时的死亡率相似（分别为 15.12%和 14.73%；差值，0.39 个百分点；95%CI，-0.36 至 1.15），每季度的改善率相似（分别为 0.10%和 0.07%；差值，-0.03 个百分点；95%CI，-0.08 至 0.02），研究结束时的死亡率相似（分别为 13.37%和 13.21%；差值，0.15 个百分点；95%CI，-0.70 至 1.01）。