Yale School of Medicine, New Haven, CT.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.
Ann Surg. 2020 Jun;271(6):985-993. doi: 10.1097/SLA.0000000000003564.
To assess whether a hospital's percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and penalty receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed.
In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need.
100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients.
A total of 695,775 patients from 2923 hospitals were included. As a hospital's percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR [95% CI]: 1.45[1.42-1.47]). Similar patterns were observed for high disproportionate share hospital (OR [95% CI]: 1.44 [1.42-1.47]; absolute difference: +7.4 percentage-points) and low socioeconomic status-serving (1.38[1.35-1.40]; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points.
Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.
评估医院黑人患者的比例与 2017 财年整体/特定领域医院获得性条件减少计划（HACRP）评分和罚款的变化是否相关。还评估了社会经济地位的差异和不成比例的医院支付份额（安全网地位的标志）的差异。
2015 财年，医疗保险开始减少高不良事件发生率医院的支付。有人担心 HACRP 处罚可能会对服务少数族裔的医院产生不利影响，导致资源减少，并加剧最需要的医院之间的差距。
从 2013 年到 2014 年，100%的医疗保险 FFS 索赔确定了年龄在 65 岁及以上的老年住院患者，患有 8 种常见的手术疾病。多水平混合效应回归确定了管理少数民族患者比例最高的十分位数的医院之间 2017 财年 HACRP 评分/罚款的差异。
共有 2923 家医院的 695775 名患者纳入研究。随着医院黑人患者比例从 0.6%上升到 32.5%（最低与最高十分位数），平均 HACRP 评分也从 5.33 上升到 6.36（分数越高表示评分越差）。HACRP 罚款的增加并没有遵循相同的逐步增加，而是在服务种族少数比例最高的十分位数内出现了明显的跳跃（45.7%比 36.7%；OR [95%CI]：1.45[1.42-1.47]）。对于高不成比例的医院支付（OR [95%CI]：1.44 [1.42-1.47]；绝对差异：+7.4 个百分点）和低社会经济地位服务（1.38[1.35-1.40]；+7.3%个百分点）医院也观察到类似的模式。考虑教学地位和患者病例组合严重程度影响的限制分析都强调了 HACRP 处罚的差异，当将医院限制在已知的最高处罚风险（更多的居民床位，更严重）时，绝对差异为+13.9、+20.5 个百分点。相比之下，限制高手术量减少了处罚差异，+6.6 个百分点。
服务少数族裔的医院受到 HACRP 的不成比例处罚。随着该计划的继续发展，需要努力确定和保护弱势机构中的患者，以确保差距不会扩大。
