Yale School of Medicine, New Haven, CT.
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.
Am Heart J. 2019 Jan;207:19-26. doi: 10.1016/j.ahj.2018.09.006. Epub 2018 Sep 30.
A key quality metric for Accountable Care Organizations (ACOs) is the rate of hospitalization among patients with heart failure (HF). Among this patient population, non-HF-related hospitalizations account for a substantial proportion of admissions. Understanding the types of admissions and the distribution of admission types across ACOs of varying performance may provide important insights for lowering admission rates.
We examined admission diagnoses among 220 Medicare Shared Savings Program ACOs in 2013. ACOs were stratified into quartiles by their performance on a measure of unplanned risk-standardized acute admission rates (RSAARs) among patients with HF. Using a previously validated algorithm, we categorized admissions by principal discharge diagnosis into: HF, cardiovascular/non-HF, and noncardiovascular. We compared the mean admission rates by admission type as well as the proportion of admission types across RSAAR quartiles (Q1-Q4).
Among 220 ACOs caring for 227,356 patients with HF, the median (IQR) RSAARs per 100 person-years ranged from 64.5 (61.7-67.7) in Q1 (best performers) to 94.0 (90.1-99.9) in Q4 (worst performers). The mean admission rates by admission types for ACOs in Q1 compared with Q4 were as follows: HF admissions: 9.8 (2.2) vs 14.6 (2.8) per 100 person years (P < .0001); cardiovascular/non-HF admissions: 11.1 (1.6) vs 15.9 (2.6) per 100 person-years (P < .0001); and noncardiovascular admissions: 42.7 (5.4) vs 69.6 (11.3) per 100 person-years (P < .0001). The proportion of admission due to HF, cardiovascular/non-HF, and noncardiovascular conditions was 15.4%, 17.5%, and 67.1% in Q1 compared with 14.6%, 15.9%, and 69.4% in Q4 (P < .007).
Although ACOs with the best performance on a measure of all-cause admission rates among people with HF tended to have fewer admissions for HF, cardiovascular/non-HF, and noncardiovascular conditions compared with ACOs with the worst performance (highest admission rates), the largest difference in admission rates were for noncardiovascular admission types. Across all ACOs, two-thirds of admissions of patients with HF were for noncardiovascular causes. These findings suggest that comprehensive approaches are needed to reduce the diverse admission types for which HF patients are at risk.
对于责任医疗组织（ACO）来说，一个关键的质量指标是心力衰竭（HF）患者的住院率。在这一患者群体中，非 HF 相关的住院治疗占了很大一部分。了解不同表现水平的 ACO 之间的住院类型以及住院类型的分布，可能为降低住院率提供重要的见解。
我们分析了 2013 年 220 个医疗保险储蓄计划 ACO 中的入院诊断。根据心力衰竭患者非计划性风险标准化急性入院率（RSAAR）测量的表现，将 ACO 分层为四分位数。使用先前验证的算法，我们根据主要出院诊断将入院分为：HF、心血管/非 HF 和非心血管。我们比较了按入院类型的平均入院率以及各 RSAAR 四分位数（Q1-Q4）之间的入院类型比例。
在 220 个为 227356 名 HF 患者提供护理的 ACO 中，每 100 人年中位数（IQR）的 RSAAR 范围从 Q1（表现最好的）的 64.5（61.7-67.7）到 Q4（表现最差的）的 94.0（90.1-99.9）。与 Q4 相比，Q1 中 ACO 按入院类型的平均入院率如下：HF 入院：9.8（2.2）vs 14.6（2.8）/100 人年（P<0.0001）；心血管/非 HF 入院：11.1（1.6）vs 15.9（2.6）/100 人年（P<0.0001）；非心血管入院：42.7（5.4）vs 69.6（11.3）/100 人年（P<0.0001）。在 Q1 中，HF、心血管/非 HF 和非心血管疾病导致的入院比例分别为 15.4%、17.5%和 67.1%，而在 Q4 中，这一比例分别为 14.6%、15.9%和 69.4%（P<0.007）。
尽管在 HF 患者全因入院率方面表现最好的 ACO 与表现最差的 ACO（即入院率最高的 ACO）相比，HF、心血管/非 HF 和非心血管疾病导致的入院次数较少，但在非心血管疾病导致的入院率方面，差异最大。在所有 ACO 中，HF 患者的三分之二入院是由于非心血管疾病引起的。这些发现表明，需要采取综合方法来降低 HF 患者面临的多种入院类型的风险。
