Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
Spine J. 2019 Aug;19(8):1340-1345. doi: 10.1016/j.spinee.2019.04.014. Epub 2019 Apr 19.
Accountable Care Organizations (ACOs) were designed to reduce healthcare costs while simultaneously improving quality. Given that the success of ACOs is predicated on controlling costs, concerns have been expressed that patients could be adversely affected through restricted access to surgery, including in the context of spine fracture care.
Evaluate the impact of Medicare ACO formation on the utilization of surgery and outcomes following spinal fractures.
Retrospective review of Medicare claims (2009-2014).
Patients treated for spinal fractures in an ACO or non-ACO.
The utilization of surgery as treatment for spinal fractures, in-hospital mortality, 90-day complications, or hospital readmission within 90-days injury.
We used a pre-post study design to compare outcomes for patients treated in ACOs versus non-ACOs. Receipt of surgery for treatment of a spinal fracture was the primary outcome, with mortality, complications and readmissions treated secondarily. We used multivariable logistic regression adjusting for confounders to determine the association between environment of care (ACO vs. non-ACO) and the outcomes of interest. In all testing, beneficiaries treated in non-ACOs during 2009 to 2011 were used as the referent.
During 2009 to 2011, 9% (n=10,866) of patients treated in non-ACOs received surgery, whereas a similar percentage (9%; n=210) underwent surgery in ACOs. This figure decreased to 8% (n=9,857) for individuals treated in non-ACOs over 2012 to 2014, although the surgical rate remained unchanged for those receiving care in an ACO (9%; n=227). There was no difference in the use of surgery among patients treated in ACOs (OR 0.96; 95% CI 0.79, 1.18) over 2012 to 2014. Similar increases in the odds of mortality were observed for both ACOs and non-ACOs during this period. A marginal, yet significant increase in complications was observed among ACOs, although there was no change in the odds of readmission.
Our study found that the formation of ACOs did not result in alterations in the use of surgery for spinal fractures or substantive changes in outcomes. As ACOs continue to evolve, more emphasis should be placed on the incorporation of measures directly related to surgical and trauma care in the determinants of risk-based reimbursements.
责任医疗组织（ACO）旨在降低医疗成本，同时提高质量。鉴于 ACO 的成功取决于控制成本，有人担心患者可能会因手术机会受限而受到不利影响，包括在脊柱骨折护理方面。
评估医疗保险 ACO 形成对脊柱骨折患者手术利用和结果的影响。
医疗保险索赔的回顾性分析（2009-2014 年）。
在 ACO 或非 ACO 接受脊柱骨折治疗的患者。
作为脊柱骨折治疗的手术利用率、院内死亡率、90 天并发症或伤后 90 天内再次住院。
我们使用前后研究设计比较了在 ACO 和非 ACO 接受治疗的患者的结果。接受脊柱骨折治疗的手术是主要结果，其次是死亡率、并发症和再入院。我们使用多变量逻辑回归调整混杂因素，以确定环境（ACO 与非 ACO）与感兴趣的结果之间的关联。在所有测试中，2009 年至 2011 年期间在非 ACO 中接受治疗的受益人为参考。
在 2009 年至 2011 年期间，9%（n=10866）的非 ACO 接受治疗的患者接受了手术，而 ACO 中有相似比例（9%；n=210）接受了手术。在 2012 年至 2014 年期间，接受非 ACO 治疗的个体的手术率下降至 8%（n=9857），而在 ACO 中接受治疗的个体的手术率保持不变（9%；n=227）。在 2012 年至 2014 年期间，ACO 治疗的患者手术使用率没有差异（OR 0.96；95%CI 0.79，1.18）。在此期间，ACO 和非 ACO 的死亡率都有类似的增加。尽管在 ACO 中，再入院的几率没有变化，但并发症的几率却略有增加。
我们的研究发现，ACO 的形成并没有导致脊柱骨折手术使用率的改变，也没有导致结果发生实质性变化。随着 ACO 的不断发展，应更加重视将与手术和创伤护理直接相关的措施纳入基于风险的报销的决定因素中。
