Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Department of Population Health Sciences, Duke University, Durham, NC, USA.
J Gen Intern Med. 2019 Dec;34(12):2740-2748. doi: 10.1007/s11606-019-05283-1. Epub 2019 Aug 26.
Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care.
To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke.
Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605).
Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated.
For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed.
Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted.
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通过对出院计划、护理协调和过渡期护理进行系统调整，参与联邦医疗保险共享储蓄计划（MSSP）管理式医疗组织（ACO）的提供者可能会影响中风后的护理提供。
评估 MSSP 与缺血性中风住院后一年患者结局的相关性。
回顾性队列研究
Get With The Guidelines（GWTG）-Stroke（2010-2014 年）
将轻度至中度偶发性缺血性中风住院患者与 Medicare 按服务收费受益人的索赔记录相关联（年龄≥65 岁；N=251605）。
结局包括出院回家、30 天全因再入院、住院时间、1 年社区（居家）时间、1 年复发性卒中和死亡率。采用差异-差异设计比较了患者的医院 MSSP 实施前后的结局：（1）出院医院选择参与 MSSP 与不参与 MSSP 相比；（2）被分配到 MSSP ACO 与未分配或两者都分配相比。为 2013 年和 2014 年 ACO 生成了独特的估计值。
对于 2013 年或 2014 年加入 MSSP 的医院，未分配到 MSSP ACO 的受益人的出院回家的概率分别降低了 2.57（95%置信区间[CI]=-4.43，-0.71）个百分点和 1.84 个百分点（CI=-3.31，-0.37）；而对于从加入 MSSP 的医院出院的患者，受益人与 ACO 之间的一致性与增加的家庭出院、缩短住院时间和增加家庭时间相关。对于 2014 年从加入 MSSP 的医院出院的患者，ACO 一致性与利用的变化无关。未观察到 MSSP 与复发性卒中和死亡率之间的关联。
在轻度至中度缺血性中风患者中，仅在同时符合 ACO 条件且从 2013 年开始实施 MSSP 的医院出院的受益人中观察到急性护理利用的显著减少。2014 年 MSSP 队列仅获得 1 年的数据，这些早期结果表明需要进一步研究。
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