Spatz Erica S, Lipska Kasia J, Dai Ying, Bao Haikun, Lin Zhenqiu, Parzynski Craig S, Altaf Faseeha K, Joyce Erin K, Montague Julia A, Ross Joseph S, Bernheim Susannah M, Krumholz Harlan M, Drye Elizabeth E
*Section of Cardiovascular Medicine, Yale University School of Medicine †Center for Outcomes Research and Evaluation, Yale-New Haven Hospital Sections of ‡Endocrinology §General Internal Medicine Departments of ∥Internal Medicine, Robert Wood Johnson Foundation Clinical Scholars Program ¶Health Policy and Management #Pediatrics, Yale University School of Medicine, New Haven, CT.
Med Care. 2016 May;54(5):528-37. doi: 10.1097/MLR.0000000000000518.
Population-based measures of admissions among patients with chronic conditions are important quality indicators of Accountable Care Organizations (ACOs), yet there are challenges in developing measures that enable fair comparisons among providers.
On the basis of consensus standards for outcome measure development and with expert and stakeholder input on methods decisions, we developed and tested 2 models of risk-standardized acute admission rates (RSAARs) for patients with diabetes and heart failure using 2010-2012 Medicare claims data. Model performance was assessed with deviance R; score reliability was tested with intraclass correlation coefficient. We estimated RSAARs for 114 Shared Savings Program ACOs in 2012 and we assigned ACOs to 3 performance categories: no different, worse than, and better than the national rate.
The diabetes and heart failure cohorts included 6.5 and 2.6 million Medicare Fee-For-Service beneficiaries aged 65 years and above, respectively. Risk-adjustment variables were age, comorbidities, and condition-specific severity variables, but not socioeconomic status or other contextual factors. We selected hierarchical negative binomial models with the outcome of acute, unplanned hospital admissions per 100 person-years. For the diabetes and heart failure measures, respectively, the models accounted for 22% and 12% of the deviance in outcomes and score reliability was 0.89 and 0.81. For the diabetes measure, 51 (44.7%) ACOs were no different, 45 (39.5%) were better, and 18 (15.8%) were worse than the national rate. The distribution of performance for the heart failure measure was 61 (53.5%), 37 (32.5%), and 16 (14.0%), respectively.
Measures of RSAARs for patients with diabetes and heart failure meet criteria for scientific soundness and reveal important variation in quality across ACOs.
基于人群的慢性病患者入院率指标是可问责医疗组织（ACO）重要的质量指标，但在制定能使各医疗机构间进行公平比较的指标方面存在挑战。
基于结局指标开发的共识标准，并在专家和利益相关者对方法决策的意见基础上，我们利用2010 - 2012年医疗保险理赔数据，为糖尿病和心力衰竭患者开发并测试了2种风险标准化急性入院率（RSAAR）模型。模型性能用偏差R评估；评分可靠性用组内相关系数检验。我们估计了2012年114个共享节约计划ACO的RSAAR，并将ACO分为3个绩效类别：与全国率无差异、低于全国率、高于全国率。
糖尿病和心力衰竭队列分别包括65岁及以上的650万和260万医疗保险按服务付费受益人。风险调整变量为年龄、合并症和特定疾病严重程度变量，但不包括社会经济地位或其他背景因素。我们选择了每100人年急性非计划住院结局的分层负二项模型。对于糖尿病和心力衰竭指标，模型分别解释了结局偏差的22%和12%，评分可靠性分别为0.89和0.81。对于糖尿病指标，51个（44.7%）ACO与全国率无差异，45个（39.5%）优于全国率，18个（15.8%）低于全国率。心力衰竭指标的绩效分布分别为61个（53.5%）、37个（32.5%）和16个（14.0%）。
糖尿病和心力衰竭患者的RSAAR指标符合科学合理性标准，并揭示了各ACO在质量上的重要差异。
