Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington;
Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington.
Hosp Pediatr. 2020 Mar;10(3):238-245. doi: 10.1542/hpeds.2019-0197. Epub 2020 Feb 3.
Health care reform may impact inpatient mental health services by increasing access and changing insurer incentives. We examined whether implementation of the 2014 Affordable Care Act (ACA) was associated with changes in psychiatric length of stay (LOS) and 30-day readmissions for pediatric patients.
We conducted an interrupted time-series analysis to evaluate LOS and 30-day readmissions during the 30 months before and 24 months after ACA implementation, with a 6-month wash-out period, on patients aged 4 to 17 years who were discharged from the psychiatry unit of a children's hospital. Differences by payer (Medicaid versus non-Medicaid) were examined in moderated interrupted time series. Logistic regression was used to examine the association between psychiatric LOS and 30-day readmissions.
There were 1874 encounters in the pre-ACA period and 2186 encounters in the post-ACA period. Compared with pre-ACA implementation, post-ACA implementation was associated with LOS that was significantly decreasing over time (pre-ACA versus post-ACA slope difference: -0.10 days per encounter per month [95% confidence interval -0.17 to -0.02]; = .01), especially for Medicaid-insured patients (pre-ACA versus post-ACA slope difference: -0.14 days per encounter per month [95% confidence interval -0.26 to -0.01]; = .03). The overall proportion of 30-day readmissions increased significantly (pre-ACA 6%, post-ACA 10%; < .05 for the difference). We found no association between LOS and 30-day readmissions.
ACA implementation was associated with a decline in psychiatric inpatient LOS over time, especially for those on Medicaid, and an increase in 30-day readmissions. LOS was not associated with 30-day inpatient readmissions. Further investigation to understand the drivers of these patterns is warranted.
医疗改革可能会通过增加可及性和改变保险公司的激励措施来影响住院精神卫生服务。我们研究了 2014 年平价医疗法案（ACA）的实施是否与儿科患者的精神科住院时间（LOS）和 30 天再入院率的变化有关。
我们进行了一项中断时间序列分析，以评估 ACA 实施前 30 个月和实施后 24 个月期间（6 个月洗脱期），在一家儿童医院精神科出院的 4 至 17 岁患者的 LOS 和 30 天再入院率。在调节中断时间序列中检查了不同付款人的差异（医疗补助与非医疗补助）。逻辑回归用于检验精神科 LOS 与 30 天再入院率之间的关系。
在 ACA 实施前有 1874 次就诊，在 ACA 实施后有 2186 次就诊。与 ACA 实施前相比，ACA 实施后 LOS 随时间显著下降（ACA 实施前与实施后斜率差异：-0.10 天/每次就诊/每月[95%置信区间-0.17 至-0.02]；P ＝.01），尤其是对医疗补助保险患者（ACA 实施前与实施后斜率差异：-0.14 天/每次就诊/每月[95%置信区间-0.26 至-0.01]；P ＝.03）。30 天再入院的总体比例显著增加（ACA 实施前为 6%，实施后为 10%；差异有统计学意义<0.05）。我们没有发现 LOS 与 30 天再入院率之间存在关联。
ACA 实施与 LOS 随时间的下降有关，尤其是对医疗补助保险患者，以及 30 天再入院率的上升。LOS 与 30 天住院再入院率无关。需要进一步调查以了解这些模式的驱动因素。
