Thompson Michael P, Cabrera Lourdes, Strobel Raymond J, Harrington Steven D, Zhang Min, Wu Xiaoting, Prager Richard L, Likosky Donald S
Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor (M.P.T., X.W., R.L.P., D.S.L.).
Michigan Society of Thoracic and Cardiovascular Surgeons-Quality Collaborative, Ann Arbor (L.C., R.L.P., D.S.L.).
Circ Cardiovasc Qual Outcomes. 2018 Sep;11(9):e004818. doi: 10.1161/CIRCOUTCOMES.118.004818.
Background Postoperative pneumonia is the most common healthcare-associated infection in cardiac surgical patients, yet their impact across a 90-day episode of care remains unknown. Our objective was to examine the relationship between pneumonia and 90-day episode payments and outcomes among Medicare beneficiaries undergoing cardiac surgery. Methods and Results Medicare claims were used to identify beneficiaries with episodes of coronary artery bypass grafting (CABG; n=56 728) and valve surgery (n=56 377) across 1045 centers between April 2014 and March 2015. Using a published diagnosis code-based algorithm, we identified pneumonia in 6.4% CABG episodes and 6.6% of valve surgery episodes. We compared price-standardized 90-day episode payments and outcome measures (postoperative length of stay, discharge to postacute care, mortality, and readmission) between beneficiaries with and without pneumonia using hierarchical regression models, adjusting for patient factors and hospital random effects. Pneumonia was associated with 24.5% higher episode payments for CABG ($46 723 versus $37 496; P<0.001) and 26.5% higher episode payments for valve surgery ($61 544 versus $48 549; P<0.001). For both cohorts, pneumonia was significantly associated with longer postoperative length of stay (CABG: +4.1 days, valve: +5.6 days), more frequent discharge to postacute care (CABG: odds ratio [OR]=1.99, valve: OR=2.17), and higher rates of 30-day mortality (CABG: OR=2.42, valve: OR=2.57) and 90-day readmission (CABG: OR=1.20, valve: OR=1.25), all P<0.001. We compared episode payments and outcomes across terciles of pneumonia rates and found that high pneumonia rate hospitals had higher episode payments and poorer outcomes compared with episodes at low pneumonia rate hospitals in both CABG and valve surgery cohorts. Conclusions Postoperative pneumonia was associated with significantly higher 90-day episode payments and inferior outcomes at the patient and hospital level. Future work should examine whether reducing pneumonia after cardiac surgery reduces episode spending and improves outcomes, which could facilitate hospital success in value-based reimbursement programs.
术后肺炎是心脏外科手术患者中最常见的医疗相关感染，但在90天的护理期间其影响尚不清楚。我们的目的是研究肺炎与接受心脏手术的医疗保险受益人的90天护理期间费用支付及预后之间的关系。
利用医疗保险理赔数据，在2014年4月至2015年3月期间，识别出1045个中心的冠状动脉搭桥术（CABG；n = 56728）和瓣膜手术（n = 56377）患者。使用已发表的基于诊断编码的算法，我们在6.4%的CABG病例和6.6%的瓣膜手术病例中识别出肺炎。我们使用分层回归模型，在调整患者因素和医院随机效应后，比较了有肺炎和无肺炎的受益人之间价格标准化的90天护理期间费用支付及预后指标（术后住院时间、转至急性后期护理机构、死亡率和再入院率）。肺炎与CABG护理期间费用支付高出24.5%（46723美元对37496美元；P<0.001）以及瓣膜手术护理期间费用支付高出26.5%（61544美元对48549美元；P<0.001）相关。对于这两个队列，肺炎均与术后住院时间显著延长（CABG：延长4.1天，瓣膜手术：延长5.6天）、更频繁转至急性后期护理机构（CABG：比值比[OR]=1.99，瓣膜手术：OR = 2.17）以及30天死亡率（CABG：OR = 2.42，瓣膜手术：OR = 2.57）和90天再入院率（CABG：OR = 1.20，瓣膜手术：OR = 1.25）升高显著相关，所有P<0.001。我们比较了肺炎发生率三分位数组之间的护理期间费用支付和预后，发现与低肺炎发生率医院的病例相比，高肺炎发生率医院在CABG和瓣膜手术队列中的护理期间费用支付更高，预后更差。
术后肺炎在患者和医院层面均与90天护理期间费用支付显著升高及预后较差相关。未来的工作应研究心脏手术后减少肺炎是否能降低护理期间费用并改善预后，这可能有助于医院在基于价值的报销计划中取得成功。
