Ibrahim Andrew M, Nathan Hari, Thumma Jyothi R, Dimick Justin B
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
Ann Surg. 2017 Oct;266(4):617-624. doi: 10.1097/SLA.0000000000002368.
To understand the impact of the Hospital Readmission Reduction Program on both future targeted and nontargeted surgical procedures.
The Hospital Readmission Reduction Program, established under the Affordable Care Act in March of 2010, placed financial penalties on hospitals with higher than expected rates of readmission beginning in 2012 for targeted medical conditions. Multiple studies have suggested a "spill-over" effect into other conditions, but the extent of that effect for specific surgical procedures is unknown.
A retrospective review 5,122,240 Medicare beneficiaries who underwent future targeted procedures (total hip replacement, total knee replacements) or nontargeted procedures (colectomy, lung resection, abdominal aortic aneurysm repair, coronary artery bypass graft, aortic valve replacement, mitral valve repair) using an interrupted time series model to assess the rates of readmission before the Hospital Readmission Reduction Program was announced (2008-2010), whereas the program was being implemented (2010-2012) and after penalties were initiated (2012-2014). We also explored if the change in readmission rates were correlated with changes in index length of stay, use of observation status, or discharge to a skilled nursing facility.
From 2008 to 2014 rates of readmission declined for both target conditions (6.8%-4.8%; slope change -0.07 to -0.10, P < 0.001) and nontarget conditions (17.1%-13.4%; slope change -0.04 to -0.11, P < 0.001). The rate of reduction was most prominent after announcement of the program between 2010 and 2012 for both targeted and nontargeted conditions. During the same time period, mean hospital length of stay decreased; nontargeted conditions (10.4-8.4 days) and targeted conditions (3.6-2.8 days). There was no correlation between hospital reduction in readmissions and use of observation-only admissions (Pearson correlation coefficient = 0.01) or discharge to a skilled nursing facility (Pearson correlation coefficient = 0.05).
Trends in readmissions after inpatient surgery are consistent with hospitals responding to financial incentives announced in the Hospital Readmission Reduction Program. There appears to be both an anticipatory effect (future targeted procedures reducing readmission before payments implemented) and a spillover effect (nontargeted procedures also reducing readmissions).
了解“降低医院再入院率计划”对未来目标性和非目标性外科手术的影响。
“降低医院再入院率计划”于2010年3月根据《平价医疗法案》设立，自2012年起对再入院率高于预期的医院就目标性医疗状况处以经济处罚。多项研究表明该计划对其他状况存在“溢出”效应，但对特定外科手术的影响程度尚不清楚。
采用中断时间序列模型对5122240名接受未来目标性手术（全髋关节置换术、全膝关节置换术）或非目标性手术（结肠切除术、肺切除术、腹主动脉瘤修复术、冠状动脉搭桥术、主动脉瓣置换术、二尖瓣修复术）的医疗保险受益人进行回顾性研究，以评估在“降低医院再入院率计划”宣布之前（2008 - 2010年）、计划实施期间（2010 - 2012年）以及处罚开始之后（2012 - 2014年）的再入院率。我们还探讨了再入院率的变化是否与首次住院时长的变化、观察状态的使用情况或转至专业护理机构的情况相关。
从2008年到2014年，目标性状况（6.8% - 4.8%；斜率变化 -0.07至 -0.10，P < 0.001）和非目标性状况（17.1% - 13.4%；斜率变化 -0.04至 -0.11，P < 0.001）的再入院率均有所下降。2010年至2012年该计划宣布后，目标性和非目标性状况的降低率最为显著。在同一时期，平均住院时长缩短；非目标性状况（10.4天 - 8.4天）和目标性状况（3.6天 - 2.8天）。医院再入院率的降低与仅采用观察性入院的情况（皮尔逊相关系数 = 0.01）或转至专业护理机构的情况（皮尔逊相关系数 = 0.05）之间没有相关性。
住院手术后再入院率的趋势与医院对“降低医院再入院率计划”中宣布的经济激励措施所做出的反应一致。似乎既存在预期效应（未来目标性手术在付款实施前降低了再入院率），也存在溢出效应（非目标性手术也降低了再入院率）。
