Department of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
Leonard Davis Institute for Health Economics, Philadelphia, Pennsylvania, USA.
BMJ Qual Saf. 2021 Mar;30(3):195-201. doi: 10.1136/bmjqs-2019-010660. Epub 2020 Mar 30.
Hospitals and health systems worldwide have adopted value-based payment to improve quality and reduce costs. In the USA, skilled nursing facilities (SNFs) are now financially penalised for higher-than-expected readmission rates. However, the extent to which SNFs contribute to, and should thus be held accountable for, readmission rates is unknown. To compare the relative contributions of hospital and SNF quality on readmission rates while controlling for unobserved patient characteristics.
Retrospective cohort study of Medicare beneficiaries, 2010-2016. Acute care hospitals and SNFs in the USA. Medicare beneficiaries with two hospitalisations followed by SNF admissions, divided into two groups: (1) patients who went to different hospitals but were discharged to the same SNF after both hospitalisations and (2) patients who went to the same hospital but were discharged to different SNFs. Hospital-level and SNF-level quality, using a lagged measure of 30-day risk-standardised readmission rates (RSRRs). Readmission within 30 days of hospital discharge.
There were 140 583 patients who changed hospitals but not SNFs, and 183 232 who changed SNFs but not hospitals. Patients who went to the lowest-performing hospitals (highest RSRR) had a 0.9% higher likelihood of readmission (p=0.005) compared with patients who went to the highest-performing hospitals (lowest RSRR). In contrast, patients who went to the lowest-performing SNFs had a 2% higher likelihood of readmission (p<0.001) compared with patients to went to the highest-performing SNFs.
The association between SNF quality and patient outcomes was larger than the association between hospital quality and patient outcomes among postacute care patients. Holding postacute care providers accountable for their quality may be an effective strategy to improve SNF quality.
全球范围内的医院和医疗系统都采用基于价值的支付方式来提高质量和降低成本。在美国，疗养院（SNF）因预期以上的再入院率而受到经济处罚。然而，疗养院对再入院率的贡献程度以及应承担的责任程度尚不清楚。本研究旨在比较在控制未观察到的患者特征的情况下，医院和疗养院质量对再入院率的相对贡献。
这是一项回顾性队列研究，纳入了 2010 年至 2016 年期间的 Medicare 受益人群。研究对象为美国的急性护理医院和疗养院。将两次住院后入住疗养院的 Medicare 受益人群分为两组：（1）两次住院均在不同医院，但出院后入住同一家疗养院的患者；（2）两次住院在同一家医院，但出院后入住不同疗养院的患者。使用 30 天风险标准化再入院率（RSRR）的滞后指标评估医院和疗养院的质量。以患者出院后 30 天内的再入院为结局。
共有 140583 例患者改变了医院但未改变疗养院，183232 例患者改变了疗养院但未改变医院。与入住表现最好的医院（最低 RSRR）的患者相比，入住表现最差的医院（最高 RSRR）的患者再入院的可能性高 0.9%（p=0.005）。相比之下，与入住表现最好的疗养院的患者相比，入住表现最差的疗养院的患者再入院的可能性高 2%（p<0.001）。
在接受急性后期护理的患者中，疗养院质量与患者结局之间的关联大于医院质量与患者结局之间的关联。追究急性后期护理提供者的质量责任可能是提高疗养院质量的有效策略。
