Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI; Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX.
Michigan Value Collaborative, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
Surgery. 2021 Feb;169(2):341-346. doi: 10.1016/j.surg.2020.07.043. Epub 2020 Sep 6.
Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments.
We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests.
Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use.
Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.
长期护理机构的使用是导致住院相关医疗费用变化的主要因素，并且越来越成为按疾病相关付费的重点。然而，人们仍然担心，限制长期护理机构的使用可能会导致再入院率、急诊部使用或其他费用的上升。我们分析了一项全州范围内的价值改善计划对降低下肢关节置换术后长期护理机构使用的影响，该计划旨在降低长期护理机构的使用，从而减少支付费用。
我们使用密歇根州价值合作组织的完整索赔数据，对接受下肢关节置换术的患者进行了回顾性队列研究。我们使用 t 检验比较了上述全州范围计划前后（2012-2013 年和 2016-2017 年） 90 天的急性后护理、再入院和急诊部门的使用率和支付率。
在所纳入的患者中，68537 例行全膝关节置换术，27131 例行全髋关节置换术。全州范围内，长期护理机构的使用和急性后护理的支付减少（长期护理机构：27.5%降至 18.1%，支付：4999 美元降至 3832 美元，P<.0001），而再入院率（8.0%降至 7.6%，P=.10）或支付（1087 美元降至 1026 美元，P=.14）并未增加。急诊部的使用增加（7.8%增至 8.9%，P<.0001）。按医院划分，长期护理机构使用变化与再入院率变化之间没有相关性（r=0.05）。医院长期护理机构使用的变化范围从+2.3%（无长期护理机构减少组）至-16.6%（长期护理机构大量减少组），与总治疗费用支付减少相关，而在再入院率/支付或急诊部门使用的变化方面无差异。
尽管长期护理机构的使用减少，但再入院率或支付费用并没有相应增加。减少关节置换术后长期护理机构的过度使用可能是按疾病相关付费节省的一个重要机会。
