Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island.
Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.
JAMA. 2020 Aug 4;324(5):481-487. doi: 10.1001/jama.2020.9935.
Critical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes.
To assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding.
DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017.
Admission to a CAH vs non-CAH.
Discharge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses.
There were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, -0.99 [95% CI, -1.08 to -0.90]; P < .001). In 2011, the CAH vs non-CAH difference in diagnoses coded increased (P < .001 for interaction between CAH and year) to 9.27 vs 12.23 (difference, -2.96 [95% CI, -3.19 to -2.73]; P < .001). Adjusted mortality rates from the model with HCC were 13.52% for CAHs vs 11.44% for non-CAHs (percentage point difference, 2.08 [95% CI, 1.74 to 2.42]; P < .001) in 2007 and increased to 15.97% vs 12.46% (difference, 3.52 [95% CI, 3.09 to 3.94]; P < .001) in 2017 (P < .001 for interaction). Adjusted mortality rates from the model without HCC were not significantly different between CAHs and non-CAHs in all years except 2007 (12.19% vs 11.74%; difference, 0.45 [95% CI, 0.12 to 0.79]; P = .008) and 2010 (12.71% vs 12.28%; difference, 0.42 [95% CI, 0.07 to 0.77]; P = .02).
For rural Medicare beneficiaries hospitalized from 2007 to 2017, CAHs submitted significantly fewer hospital diagnosis codes than non-CAHs, and short-term mortality rates adjusted for preexisting conditions but not in-hospital comorbidity measures were not significantly different by hospital type in most years. The findings suggest that short-term mortality outcomes at CAHs may not differ from those of non-CAHs after accounting for different coding practices for in-hospital comorbidities.
农村社区由关键访问医院（CAH）提供医疗服务。据报道，CAH 的死亡率相对高于非 CAH。由于医疗保险按成本向 CAH 报销，CAH 可能比非 CAH 报告的诊断少，这可能会影响风险调整后结局的比较。
在考虑诊断编码差异后，评估 CAH 和非 CAH 之间的风险调整死亡率的连续差异。
设计、地点和参与者： 对 2007 年至 2017 年期间接受美国 CAH 和非 CAH 治疗的农村医疗保险费用服务受益人的肺炎、心力衰竭、慢性阻塞性肺疾病、心律失常、尿路感染、败血症和中风的连续病例系列研究。最后随访日期为 2017 年 12 月 31 日。
入住 CAH 与非 CAH。
出院诊断计数，包括 2010 年至 2011 年 Medicare 扩大住院允许的计费代码数量时的趋势，以及在调整人口统计学、主要诊断、预先存在的疾病、有或没有进一步调整分层条件类别（HCC）评分的情况下，了解医院内次要诊断的贡献的同时调整住院和 30 天内出院死亡率。
共有 4094720 例住院（17% CAH）和 2850194 例独特的医疗保险受益人的 720 例（平均[SD]年龄，76.3[11.7]岁；55.5%为女性）。CAH 中的患者年龄较大（中位数年龄，80.1 岁 vs 76.8 岁），且更可能为女性（58% vs 55%）。2010 年，CAH 的调整后平均出院诊断计数为 7.52，而非 CAH 为 8.53（差异，-0.99[95%CI，-1.08 至-0.90]；P<0.001）。2011 年，CAH 与非 CAH 编码诊断差异增加（CAH 和年份之间的交互作用 P<0.001）至 9.27 与 12.23（差异，-2.96[95%CI，-3.19 至-2.73]；P<0.001）。HCC 模型的调整死亡率为 CAH 为 13.52%，而非 CAH 为 11.44%（百分比差异，2.08[95%CI，1.74 至 2.42]；P<0.001），2007 年增加至 CAH 为 15.97%，而非 CAH 为 12.46%（差异，3.52[95%CI，3.09 至 3.94]；P<0.001）。（P<0.001 为交互作用）。在所有年份（除 2007 年（12.19% 对 11.74%；差异，0.45[95%CI，0.12 至 0.79]；P=0.008）和 2010 年（12.71% 对 12.28%；差异，0.42[95%CI，0.07 至 0.77]；P=0.02）外，CAH 和非 CAH 之间的调整死亡率没有显著差异。
对于 2007 年至 2017 年住院的农村医疗保险受益人，CAH 提交的医院诊断代码明显少于非 CAH，在大多数年份，根据预先存在的疾病调整的短期死亡率，而不是医院内合并症测量，在医院类型之间没有显著差异。研究结果表明，在考虑到医院内合并症的不同编码实践后，CAH 的短期死亡率结果可能与非 CAH 不同。
