Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.
Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA.
Health Serv Res. 2021 Oct;56(5):817-827. doi: 10.1111/1475-6773.13642. Epub 2021 Mar 17.
To determine whether vertically integrated hospital and skilled nursing facility (SNF) care is associated with more efficient use of postdischarge care and better outcomes.
Medicare provider, beneficiary, and claims data from 2012 to 2014.
We compared facility characteristics, quality of care, and health care use for hospital-based SNFs and "virtually integrated" SNFs (defined as freestanding SNFs with close referral relationships with a single hospital) relative to nonintegrated freestanding SNFs. Among patients admitted to integrated SNFs, we estimated differences in health care use and outcomes for patients originating from the parent hospital (ie, receiving vertically integrated care) versus other hospitals using linear regressions that included SNF fixed effects. We estimated bounds for our main estimates that incorporated potential omitted variables bias.
We identified hospital-based SNFs based on provider data. We defined virtually integrated SNFs based on patient flows between hospitals and SNFs. We identified SNF episodes, preceding hospital stays, patient characteristics, health care use, and patient outcomes using Medicare data.
Consistent with prior research, integrated SNFs performed better on quality measures and health care use relative to nonintegrated SNFs (eg, hospital-based SNFs had 11-day shorter stays compared with nonintegrated SNFs adjusting for patient characteristics, P < .001). Stroke patients admitted to hospital-based SNFs from the parent hospital had shorter preceding hospital stays (adjusted difference: -1.2 days, P = .001) and shorter initial SNF stays (adjusted difference: -2.7 days, P = .049); estimates were attenuated but still robust accounting for potential omitted variables bias. For stroke patients, associations between vertically integrated care and other outcomes were either statistically insignificant or not robust to accounting for potential omitted variables bias.
Vertically integrated hospital and SNF care was associated with shorter hospital and SNF stays. However, there were few beneficial associations with other outcomes, suggesting limited coordination benefits from vertical integration.
确定垂直整合的医院和熟练护理机构（SNF）护理是否与更有效的出院后护理和更好的结果相关。
2012 年至 2014 年的医疗保险提供者、受益人和索赔数据。
我们比较了医院内 SNF 和“虚拟整合”SNF（定义为与单个医院有密切转诊关系的独立 SNF）与非整合独立 SNF 的设施特征、护理质量和医疗保健使用情况。在接受整合 SNF 治疗的患者中，我们使用包括 SNF 固定效应的线性回归来估计源自母医院（即接受垂直整合护理）的患者与来自其他医院的患者在医疗保健使用和结果方面的差异。我们对我们的主要估计值进行了上下限估计，其中纳入了潜在的遗漏变量偏差。
我们根据提供者数据确定了医院内 SNF。我们根据医院和 SNF 之间的患者流动情况定义了虚拟整合 SNF。我们使用医疗保险数据确定了 SNF 发作、先前的住院治疗、患者特征、医疗保健使用和患者结局。
与先前的研究一致，整合 SNF 在质量指标和医疗保健使用方面的表现优于非整合 SNF（例如，在调整患者特征后，与非整合 SNF 相比，医院内 SNF 的住院时间缩短了 11 天，P < 0.001）。从母医院转入医院内 SNF 的中风患者先前的住院时间较短（调整差异：-1.2 天，P = 0.001），初始 SNF 住院时间也较短（调整差异：-2.7 天，P = 0.049）；在考虑潜在遗漏变量偏差的情况下，这些估计值虽然有所减弱，但仍然稳健。对于中风患者，垂直整合护理与其他结果之间的关联要么在统计学上无意义，要么在考虑潜在遗漏变量偏差的情况下不稳健。
垂直整合的医院和 SNF 护理与较短的医院和 SNF 住院时间相关。然而，与其他结果相关的有益关联很少，这表明垂直整合的协调效益有限。
