医疗保险受益人30天发作期支付与急性心肌梗死结局之间的关联。
Association Between 30-Day Episode Payments and Acute Myocardial Infarction Outcomes Among Medicare Beneficiaries.
作者信息
Wadhera Rishi K, Joynt Maddox Karen E, Wang Yun, Shen Changyu, Bhatt Deepak L, Yeh Robert W
机构信息
From the Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (R.K.W., D.L.B.); Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., Y.W., C.S., R.W.Y.); Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (K.E.J.M.); and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (Y.W.).
出版信息
Circ Cardiovasc Qual Outcomes. 2018 Mar;11(3):e004397. doi: 10.1161/CIRCOUTCOMES.117.004397.
BACKGROUND
Recent policy efforts have focused on improving the value of acute myocardial infarction (AMI) care. Medicare payment programs, for example, increasingly evaluate hospital performance based on spending, as determined by payments made to institutions and providers, and outcome measures for a longitudinal episode of AMI care. Little is known about the relationship between total 30-day payments-both in the inpatient and immediate postdischarge timeframe-and outcomes after an admission for AMI.
METHODS AND RESULTS
Using Medicare claims data, we identified Medicare fee-for-service beneficiaries ≥65 years of age who were hospitalized at an acute-care hospital for AMI between July 1, 2011, and June 30, 2014, and examined the association between hospital-level 30-day payments for an episode of AMI care and patient 30-day mortality using mixed regression models with a logit link function and random hospital intercepts. Our cohort included 642 105 index hospitalizations for AMI at 2319 acute-care hospitals. Overall mean 30-day episode payments per beneficiary were $22 128 (SD, $1750). The observed 30-day mortality rate was 12.9%. Higher 30-day payments were associated with lower 30-day mortality after adjustment for patient characteristics and comorbidities (adjusted odds ratio for additional $1000 payments, 0.986; 95% confidence interval, 0.979-0.992; <0.001). Additional adjustment for potential mediating factors, including hospital characteristics, coronary revascularization rates, and discharge disposition, did not significantly attenuate the relationship (adjusted odds ratio for additional $1000 payments, 0.987; 95% confidence interval, 0.980-0.994; <0.001).
CONCLUSIONS
Higher hospital-level 30-day payments-both inpatient and in multiple settings after discharge-for AMI care were associated with lower 30-day mortality among beneficiaries. This may have implications for payment programs that incent reduction in payments without considering value.
背景
近期的政策举措聚焦于提升急性心肌梗死（AMI）护理的价值。例如，医疗保险支付项目越来越多地依据支出情况评估医院绩效，支出由向机构和提供者支付的费用决定，同时还依据AMI护理纵向病程的结局指标进行评估。对于AMI入院后30天内的总支付（包括住院期间和出院后即刻时间段）与结局之间的关系，人们了解甚少。
方法与结果
利用医疗保险理赔数据，我们确定了2011年7月1日至2014年6月30日期间在急症医院因AMI住院的65岁及以上医疗保险按服务付费受益人，并使用具有logit链接函数和随机医院截距的混合回归模型，研究了AMI护理病程的医院层面30天支付与患者30天死亡率之间的关联。我们的队列包括2319家急症医院的642105例AMI首次住院病例。每位受益人的30天病程平均支付为22128美元（标准差为1750美元）。观察到的30天死亡率为12.9%。在对患者特征和合并症进行调整后，较高的30天支付与较低的30天死亡率相关（每额外支付1000美元的调整优势比为0.986；95%置信区间为0.979 - 0.992；P<0.001）。对潜在中介因素进行额外调整，包括医院特征、冠状动脉血运重建率和出院处置情况，并未显著减弱这种关系（每额外支付1000美元的调整优势比为0.987；95%置信区间为0.980 - 0.994；P<0.001）。
结论
AMI护理在医院层面较高的30天支付（包括住院期间和出院后的多种情况）与受益人较低的30天死亡率相关。这可能对那些在不考虑价值的情况下激励降低支付的支付项目产生影响。
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