University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA.
University of Michigan Medical School, Ann Arbor, MI, USA.
BMJ. 2019 Jul 3;366:l4109. doi: 10.1136/bmj.l4109.
To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes.
Regression discontinuity design applied to a retrospective cohort from inpatient Medicare claims.
3238 acute care hospitals in the United States.
Medicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334).
Hospital receipt of a penalty in the first year of the HACRP.
Episode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality.
Of 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of -0.16 hospital acquired conditions per 1000 episodes (95% confidence interval -0.53 to 0.20), -0.36 percentage points in 30 day readmission (-1.06 to 0.33), and -0.04 percentage points in 30 day mortality (-0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics.
Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.
评估美国医院获得性条件减少计划（HACRP）中医院的处罚与随后临床结果变化之间的关联。
应用于回顾性队列的回归不连续性设计，该队列来自住院 Medicare 索赔。
美国 3238 家急性护理医院。
2014 年 7 月 23 日至 2016 年 11 月 30 日从急性护理医院出院且有资格获得至少一种目标性医院获得性疾病（n=15470334）的 Medicare 按服务项目付费的受益人群。
HACRP 实施的第一年医院收到处罚。
每 1000 例的目标性医院获得性疾病的发作水平计数、30 天再入院率和 30 天死亡率。
在 2015 财年受到 HACRP 处罚的 724 家医院中，有 708 家医院在研究中。受处罚医院的医院获得性疾病平均发生率为每 1000 例 2.72 例，未受处罚医院的医院获得性疾病平均发生率为每 1000 例 2.06 例；30 天再入院率分别为 14.4%和 14.0%，30 天死亡率均为 9.0%。与未受处罚的医院相比，受处罚的医院更有可能是大型教学医院，且拥有更多低社会经济地位的患者。HACRP 处罚与每 1000 例医院获得性疾病的变化量无关（95%置信区间为-0.53 至 0.20），与 30 天再入院率的变化量无关（-0.36 个百分点，-1.06 至 0.33），与 30 天死亡率的变化量无关（-0.04 个百分点，-0.59 至 0.52）。未观察到医院特征方面的临床改善有明显模式。
处罚与医院获得性疾病、30 天再入院率或 30 天死亡率的变化率没有显著关联，似乎不会带来有意义的临床改善。HACRP 通过不成比例地处罚照顾更多弱势群体的医院，可能会加剧医疗保健方面的不平等。
Zotero 插件
