Pimperl Alexander, Schulte Timo, Mühlbacher Axel, Rosenmöller Magdalena, Busse Reinhard, Groene Oliver, Rodriguez Hector P, Hildebrandt Helmut
1 Health Policy and Management, School of Public Health, University of California , Berkeley, Berkeley, California.
2 Department of Health, University of Witten/Herdecke , Witten, Germany .
Popul Health Manag. 2017 Jun;20(3):239-248. doi: 10.1089/pop.2016.0036. Epub 2016 Aug 26.
A central goal of accountable care organizations (ACOs) is to improve the health of their accountable population. No evidence currently links ACO development to improved population health. A major challenge to establishing the evidence base for the impact of ACOs on population health is the absence of a theoretically grounded, robust, operationally feasible, and meaningful research design. The authors present an evaluation study design, provide an empirical example, and discuss considerations for generating the evidence base for ACO implementation. A quasi-experimental study design using propensity score matching in combination with small-scale exact matching is implemented. Outcome indicators based on claims data were constructed and analyzed. Population health is measured by using a range of mortality indicators: mortality ratio, age at time of death, years of potential life lost/gained, and survival time. The application is assessed using longitudinal data from Gesundes Kinzigtal, one of the leading population-based ACOs in Germany. The proposed matching approach resulted in a balanced control of observable differences between the intervention (ACO) and control groups. The mortality indicators used indicate positive results. For example, 635.6 fewer years of potential life lost (2005.8 vs. 2641.4; t-test: sig. P < 0.05*) in the ACO intervention group (n = 5411) attributable to the ACO, also after controlling for a potential (indirect) immortal time bias by excluding the first half year after enrollment from the outcome measurement. This empirical example of the impact of a German ACO on population health can be extended to the evaluation of ACOs and other integrated delivery models of care.
accountable care organizations (ACOs)的一个核心目标是改善其责任人群的健康状况。目前尚无证据表明ACO的发展与人群健康改善之间存在关联。为ACO对人群健康影响建立证据基础的一个主要挑战是缺乏一个理论基础扎实、稳健、操作可行且有意义的研究设计。作者提出了一种评估研究设计，给出了一个实证例子，并讨论了为ACO实施生成证据基础的相关考虑因素。实施了一种使用倾向得分匹配并结合小规模精确匹配的准实验研究设计。构建并分析了基于索赔数据的结果指标。通过一系列死亡率指标来衡量人群健康：死亡率、死亡时年龄、潜在寿命损失/增加年数以及生存时间。使用来自德国领先的基于人群的ACO之一的Gesundes Kinzigtal的纵向数据对该应用进行了评估。所提出的匹配方法实现了对干预组（ACO）和对照组之间可观察差异的平衡控制。所使用的死亡率指标显示出积极结果。例如，ACO干预组（n = 5411）中，由于ACO导致的潜在寿命损失减少了635.6年（2005.8年对2641.4年；t检验：显著性P < 0.05*），在从结果测量中排除入组后的前半年以控制潜在的（间接）不朽时间偏差后也是如此。这个德国ACO对人群健康影响的实证例子可以扩展到对ACO和其他综合护理提供模式的评估。
