Division of General Internal Medicine, University of Pennsylvania, Philadelphia.
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.
JAMA Intern Med. 2019 May 1;179(5):617-623. doi: 10.1001/jamainternmed.2018.7998.
Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care.
To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary's home zip code and the closest home health agency and the closest skilled nursing facility as an instrument.
Receipt of postacute care at home vs in a skilled nursing facility.
Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode.
A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean [SD] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (-2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (-1.9 percentage points; 95% CI, -12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (-$5384; 95% CI, -$6932 to -$3837; P < .001), as was total Medicare payment within the first 60 days after admission (-$4514; 95% CI, -$6932 to -$3837; P < .001).
Among Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.
重要性：在美国，使用康复后期护理是很常见且费用高昂的，但选择康复后期护理场所是否重要仍存在很大的不确定性。鉴于新的替代支付模式将患者推向成本较低的护理场所，了解这些权衡取舍尤为重要。
目的：调查患者出院后选择居家护理还是入住护理型康复机构，对患者结局和医疗保险出院后护理费用的影响。
设计、场所和参与者：本回顾性队列研究使用了美国短期急性护理医院的医疗保险索赔数据，以及 2010 年 1 月 1 日至 2016 年 12 月 31 日护理型康复机构和居家健康评估数据，对出院后接受居家护理或入住护理型康复机构的医疗保险受益人的数据进行分析。为了解决治疗选择的内生性问题，采用工具变量法，使用受益人家中邮政编码与最近的居家健康机构和最近的护理型康复机构之间的差异作为工具变量。
暴露：居家 vs 护理型康复机构接受康复后期护理。
主要结局和措施：出院后 30 天内再入院、出院后 30 天内死亡、康复后期护理期间功能状态改善，以及医疗保险对康复后期护理的支付和 60 天内的总支付。
结果：在研究期间，共有 17235854 例（62.2%为女性，37.8%为男性；平均[标准差]年龄为 80.5[7.9]岁）出院，其中 38.8%出院后居家接受居家护理，61.2%出院后入住护理型康复机构。与入住护理型康复机构相比，出院后居家接受护理与 30 天内再入院率增加 5.6 个百分点相关（95%CI，0.8-10.3；P=0.02）。30 天内死亡率没有显著差异（-2.0 个百分点；95%CI，0.8-10.3；P=0.12）或功能状态改善（-1.9 个百分点；95%CI，-12.0 至 8.2；P=0.71）。与入住护理型康复机构相比，居家接受护理的医疗保险对康复后期护理的支付显著降低（-5384 美元；95%CI，-6932 至-3837；P<0.001），医疗保险在初次入院后 60 天内的总支付也显著降低（-4514 美元；95%CI，-6932 至-3837；P<0.001）。
结论和相关性：在有资格接受居家或护理型康复机构康复后期护理的医疗保险受益人中，出院后居家接受护理与再入院率较高、死亡率或功能结局无明显差异，以及医疗保险支付减少相关。
