Division of Cardiology (A.E.L., K.J.M., J.D.N., J.C.M., F.A.M., L.A.A., K.S.R.), University of Colorado Anschutz Medical Campus, Aurora.
Division of Cardiology, Denver Health and Hospital Authority, CO (A.E.L.).
Circ Cardiovasc Qual Outcomes. 2021 Mar;14(3):e006570. doi: 10.1161/CIRCOUTCOMES.120.006570. Epub 2021 Mar 3.
Among Medicare value-based payment programs for acute myocardial infarction (AMI), the Hospital Readmissions Reduction Program uses () codes to identify the program denominator, while the Bundled Payments for Care Improvement Advanced program uses diagnosis-related groups (DRGs). The extent to which these programs target similar patients, whether they target the intended population (type 1 myocardial infarction), and whether outcomes are comparable between cohorts is not known.
In a retrospective study of 2176 patients hospitalized in an integrated health system, a cohort of patients assigned a principal diagnosis of AMI and a cohort of patients assigned an AMI DRG were compared according to patient-level agreement and outcomes such as mortality and readmission.
One thousand nine hundred thirty-five patients were included in the cohort compared with 662 patients in the DRG cohort. Only 421 patients were included in both AMI cohorts (19.3% agreement). DRG cohort patients were older (70 versus 65 years, <0.001), more often female (48% versus 30%, <0.001), and had higher rates of heart failure (52% versus 33%, <0.001) and kidney disease (42% versus 25%, <0.001). Comparing outcomes, the DRG cohort had significantly higher unadjusted rates of 30-day mortality (6.6% versus 2.5%, <0.001), 1-year mortality (21% versus 8%, <0.001), and 90-day readmission (26% versus 19%, =0.006) than the cohort. Two observations help explain these differences: 61% of cohort patients were assigned procedural DRGs for revascularization instead of an AMI DRG, and type 1 myocardial infarction patients made up a smaller proportion of the DRG cohort (34%) than the cohort (78%).
The method used to identify denominators for value-based payment programs has important implications for the patient characteristics and outcomes of the populations. As national and local quality initiatives mature, an emphasis on codes to define AMI cohorts would better represent type 1 myocardial infarction patients.
在医疗保险基于价值的支付计划中，急性心肌梗死（AMI）的医院再入院减少计划使用（）代码来确定计划分母，而改善护理捆绑支付高级计划则使用诊断相关组（DRGs）。这些计划针对的是相似的患者，还是针对目标人群（1 型心肌梗死），以及两个队列的结果是否具有可比性尚不清楚。
在一项对一个综合医疗系统中 2176 名住院患者的回顾性研究中，比较了一组被分配主要 AMI 诊断的患者和一组被分配 AMI DRG 的患者，比较了患者水平的一致性和死亡率和再入院等结果。
与 DRG 队列 662 例相比，有 1935 例患者纳入了 AMI 队列。只有 421 例患者同时纳入了 AMI 队列（一致性 19.3%）。DRG 队列患者年龄较大（70 岁比 65 岁，<0.001），女性更多（48%比 30%，<0.001），心力衰竭（52%比 33%，<0.001）和肾病（42%比 25%，<0.001）的发生率更高。比较结果，DRG 队列 30 天死亡率（6.6%比 2.5%，<0.001）、1 年死亡率（21%比 8%，<0.001）和 90 天再入院率（26%比 19%，=0.006）明显高于 AMI 队列。两个观察结果有助于解释这些差异：AMI 队列中 61%的患者被分配了血管重建的程序性 DRG，而不是 AMI DRG，并且 1 型心肌梗死患者在 DRG 队列中的比例（34%）低于 AMI 队列（78%）。
用于确定基于价值的支付计划分母的方法对人群的患者特征和结果有重要影响。随着国家和地方质量计划的成熟，强调使用（）代码来定义 AMI 队列将更好地代表 1 型心肌梗死患者。
