MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
MedStar Health Research Institute, Washington, DC.
Ann Surg. 2020 Oct;272(4):612-619. doi: 10.1097/SLA.0000000000004203.
To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time.
Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90).
Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90.
PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013).
Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.
通过扩展状态、不同程度的安全网负担以及随时间的推移，评估平价医疗法案的医疗补助扩张对医院层面患者安全指标的影响。
医疗补助的扩大引起了人们对医院系统中额外涌入的医疗和社会复杂人群的担忧。医疗补助和未参保支付人组合的增加是否会影响医院绩效指标在很大程度上尚不清楚。我们试图评估扩张对医疗保险和医疗补助服务中心认可的患者安全指标（PSI-90）的影响。
从 3 个扩张州（肯塔基州、马里兰州、新泽西州）和 2 个非扩张州（佛罗里达州、北卡罗来纳州）的州住院数据库（2012-2015 年）中确定了 358 家医院。使用医疗保健研究与质量局模块计算 PSI-90 得分。将医院的医疗补助和未参保患者分为安全网负担（SNB）四分位。对医院层面进行多元线性回归，以衡量扩张和 SNB 变化对 PSI-90 的影响。
所有医院的 PSI-90 随时间推移均呈下降趋势（安全性提高）（-5.2%），扩张州与非扩张州的降幅相当（-5.9%对-4.7%，P=0.441），扩张州和非扩张州高 SNB 医院的降幅也相当（-3.9%对-5.2%，P=0.639）。ACA 前 SNB 四分位数不能预测 ACA 后 PSI-90 的变化。然而，当医院的 SNB 增加 5%时，与非扩张州相比，扩张州的安全事件明显增加（1.87%对-14.0%，P=0.013）。
尽管患者安全总体有所改善，但 SNB 的增加与扩张州的安全事件增加有关。因此，医疗保险和医疗补助服务中心的措施可能会在医疗补助扩张后无意中惩罚 SNB 增加的医院。
