From the Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.
Ann Surg. 2014 Apr;259(4):677-81. doi: 10.1097/SLA.0000000000000425.
We sought to determine whether the changes in incentive design in phase 2 of Medicare's flagship pay-for-performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals.
The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown.
We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003 to 2009 in 12 states (n = 861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier versus non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates.
After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG [odds ratio (OR) = 1.09; 95% confidence interval (CI), 0.92-1.28] or joint replacement (OR = 0.81; 95% CI, 0.58-1.12). Similarly, there were no significant improvements in serious complications for CABG (OR = 1.05; 95% CI, 0.97-1.14) or joint replacement (OR = 1.12; 95% CI, 1.01-1.23). Analysis of the "worst" quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality [(OR = 1.01; 95% CI, 0.78-1.32) for CABG and (OR = 0.96; 95% CI, 0.22-4.26) for joint replacement] or serious complication rates [(OR = 1.08; 95% CI, 0.88-1.34) for CABG and (OR = 0.92; 95% CI, 0.67-1.28) for joint replacement].
Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.
我们旨在确定医疗保险旗舰绩效支付计划（即 Premier 医院质量激励示范计划，HQID）第二阶段激励设计的变化是否降低了参与医院的外科手术死亡率或并发症发生率。
Premier HQID 于 2003 年启动，旨在奖励表现出色的医院。该计划于 2006 年重新设计激励结构，以奖励那些实现显著改善的医院。激励结构变化对手术人群结果的影响尚不清楚。
我们在 2003 年至 2009 年期间，在 12 个州的 Hospital Compare 中对在 Premier 医院和非 Premier 医院接受冠状动脉旁路移植术（CABG）、髋关节置换术和膝关节置换术的患者进行了出院数据评估（n=861,411）。我们评估了 2006 年激励结构变化对严重并发症和 30 天死亡率的影响。在这些分析中，我们使用多项逻辑回归模型对患者特征进行了调整。为了考虑到随着时间的推移而改善的结果，我们使用差异法技术来比较 Premier 医院和非 Premier 医院的趋势。我们根据风险调整后的死亡率和严重并发症率将医院分为五组后，再次进行了分析。
在 2006 年对 Premier 医院的激励措施进行重组后，心脏和骨科患者的风险调整死亡率和并发症发生率均有所降低。然而，在考虑到非 Premier 医院的时间趋势后，CABG 的死亡率（比值比[OR] = 1.09；95%置信区间[CI]，0.92-1.28）或关节置换术（OR = 0.81；95%CI，0.58-1.12）均无显著改善。同样，CABG（OR = 1.05；95%CI，0.97-1.14）或关节置换术（OR = 1.12；95%CI，1.01-1.23）的严重并发症也无显著改善。对激励结构变化目标的“最差”五分位数医院的分析也未显示死亡率发生变化[CABG 的比值比（OR）=1.01；95%CI，0.78-1.32]或严重并发症发生率[CABG 的 OR = 0.96；95%CI，0.22-4.26）或关节置换术（OR = 0.96；95%CI，0.22-4.26）。
尽管最近对激励结构进行了改进，但 Premier HQID 并未改善参与医院的外科手术结果。除非进行重大重新设计，否则按绩效付费可能不是改善手术结果的成功策略。
