College of Systems Engineering, National University of Defense Technology, Changsha, China.
Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada.
Acad Emerg Med. 2019 Aug;26(8):856-866. doi: 10.1111/acem.13635. Epub 2019 Jul 18.
Pay-for-performance (P4P) programs have been implemented in various forms to reduce emergency department (ED) patient length of stay (LOS). This retrospective study investigated to what extent the timing of patient disposition in Metro Vancouver EDs was influenced by a LOS-based P4P program.
We analyzed ED visit records of four major hospitals in Metro Vancouver, Canada. For each ED, we individually tested whether LOS was distributed discontinuously at the LOS target before and after the P4P program was terminated. For the P4P effective period, we examined whether patients discharged just prior to the LOS target had a higher 7-day return-and-admission (RA) rate-the probability that a patient, after being discharged home, returned to any ED within 7 days and was admitted to an inpatient unit-than patients discharged just after the target.
Prior to the termination of the P4P program, in all four EDs, the LOS density of admitted patients was discontinuous and had a significant drop at the P4P 10-hours admission LOS target; a similar phenomenon was observed among discharged patients at the 4-hours discharge LOS target, but only in the two lower-volume EDs. Furthermore, in a lower-volume ED, patients who were discharged right before the 4-hours P4P LOS target had a higher 7-day RA rate than patients discharged right after the LOS target. After the termination of the discharge incentive, the discontinuity at the discharge LOS target became less evident, but patients were still more frequently admitted just before 10 hours in three of the four EDs as the local health authority continued to support the admission incentive scheme after the government terminated the P4P program.
The LOS-based financial incentive scheme appears to have influenced the timing of ED patient dispositions. The results suggest mixed consequences of the P4P program-it can reduce access block for admitted patients but may also lead to discharges associated with return visits and admissions.
已采用各种形式的按效付费（P4P）计划来缩短急诊部（ED）患者的住院时间（LOS）。本回顾性研究调查了基于 LOS 的 P4P 计划对大温哥华 ED 患者出院时间的影响程度。
我们分析了加拿大大温哥华四家主要医院的 ED 就诊记录。对于每个 ED，我们分别测试了在 P4P 计划终止前后， LOS 是否在 LOS 目标值处呈不连续分布。在 P4P 有效期间，我们检查了在 LOS 目标值前刚刚出院的患者，其在 7 天内再次就诊和入院（RA）的概率（患者出院后返回任何 ED 并在 7 天内入院到住院部的概率）是否高于刚过目标值出院的患者。
在 P4P 计划终止之前，在所有四家 ED 中，入院患者的 LOS 密度均不连续，在 P4P 10 小时入院 LOS 目标值处显著下降；在 4 小时出院 LOS 目标值处，出院患者也出现了类似的现象，但仅在两个低容量 ED 中观察到。此外，在一个低容量 ED 中，在 4 小时 P4P LOS 目标值前出院的患者在 7 天内再次就诊和入院的概率高于在 LOS 目标值后出院的患者。在终止出院激励措施后，在出院 LOS 目标值处的不连续性变得不那么明显，但在四个 ED 中的三个中，患者在接近 10 小时时仍更频繁地被收治，因为当地卫生当局在政府终止 P4P 计划后继续支持入院激励计划。
基于 LOS 的财务激励计划似乎影响了 ED 患者的出院时间。结果表明 P4P 计划具有混合后果-它可以减少入院患者的准入障碍，但也可能导致与再次就诊和入院相关的出院。
