Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles.
Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, California.
JAMA Cardiol. 2021 Jul 1;6(7):791-800. doi: 10.1001/jamacardio.2021.0611.
The Centers for Medicare & Medicaid Services uses a new peer group-based payment system to compare hospital performance as part of its Hospital Readmissions Reduction Program, which classifies hospitals into quintiles based on their share of dual-eligible beneficiaries for Medicare and Medicaid. However, little is known about the association of a hospital's share of dual-eligible beneficiaries with the quality of care and outcomes for patients with heart failure (HF).
To evaluate the association between a hospital's proportion of patients with dual eligibility for Medicare and Medicaid and HF quality of care and outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study evaluated 436 196 patients hospitalized for HF using the Get With The Guidelines-Heart Failure registry from January 1, 2010, to December 31, 2017. The analysis included patients 65 years or older with available data on dual-eligibility status. Hospitals were divided into quintiles based on their share of dual-eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models. Data analysis was performed from April 1, 2020, to January 1, 2021.
The primary outcome was 30-day all-cause readmission. The secondary outcomes included in-hospital mortality, 30-day HF readmissions, 30-day all-cause mortality, and HF process of care measures.
A total of 436 196 hospitalized HF patients 65 years or older from 535 hospital sites were identified, with 258 995 hospitalized patients (median age, 81 years; interquartile range, 74-87 years) at 455 sites meeting the study criteria and included in the primary analysis. A total of 258 995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual-eligibility quintile (quintile 5) tended to care for patients who were younger, were more likely to be female, belonged to racial minority groups, or were located in rural areas compared with quintile 1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility were associated with lower rates of key process measures, including evidence-based β-blocker prescription, measure of left ventricular function, and anticoagulation for atrial fibrillation or atrial flutter. Differences in clinical outcomes were seen with higher 30-day all-cause (adjusted odds ratio, 1.24; 95% CI, 1.14-1.35) and HF (adjusted odds ratio, 1.14; 95% CI, 1.03-1.27) readmissions in higher dual-eligible quintile 5 sites compared with quintile 1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in quintile 1 vs quintile 5 hospitals.
In this cohort study, hospitals with a higher share of dual-eligible patients provided care with lower rates of some of the key HF quality of care process measures and with higher 30-day all-cause or HF readmissions compared with lower dual-eligibility quintile hospitals.
医疗保险和医疗补助服务中心 (Centers for Medicare & Medicaid Services) 使用新的同行组为基础的支付系统来比较医院的绩效，作为其医院再入院减少计划的一部分，该计划根据医疗保险和医疗补助的双重资格受益人的份额将医院分为五分位数。然而，人们对医院双重资格受益人的份额与心力衰竭 (HF) 患者的护理质量和结果之间的关联知之甚少。
评估医院中同时具有医疗保险和医疗补助双重资格的患者比例与 HF 护理质量和结果之间的关系。
设计、地点和参与者：本回顾性队列研究使用 Get With The Guidelines-Heart Failure 登记处，对 2010 年 1 月 1 日至 2017 年 12 月 31 日期间因 HF 住院的 436196 名患者进行评估。分析纳入 65 岁及以上且有双重资格状态数据的患者。根据双重资格患者的比例，医院被分为五分位数。使用未经调整和调整后的多变量逻辑回归模型分析质量和结果。数据分析于 2020 年 4 月 1 日至 2021 年 1 月 1 日进行。
主要结局是 30 天全因再入院。次要结局包括住院期间死亡率、30 天 HF 再入院、30 天全因死亡率和 HF 护理过程措施。
共确定了 535 个医院站点的 436196 名 65 岁及以上因 HF 住院的患者，其中 455 个医院站点的 258995 名住院患者（中位数年龄 81 岁；四分位间距 74-87 岁）符合研究标准并纳入主要分析。共有 258995 例 HF 住院患者来自 455 个医院被纳入研究的主要分析。与五分位数 1 相比，五分位数 5 中接受治疗的医院的患者更年轻、更可能是女性、属于少数族裔群体或位于农村地区。在多变量调整后，具有最高五分位数双重资格的医院与较低的关键流程措施率相关，包括基于证据的β受体阻滞剂处方、左心室功能测量以及房颤或房扑的抗凝治疗。与五分位数 1 相比，五分位数 5 中较高的 30 天全因（调整后的优势比，1.24；95%置信区间，1.14-1.35）和 HF（调整后的优势比，1.14；95%置信区间，1.03-1.27）再入院率与较高的双重资格五分位数 5 站点相关。五分位数 1 与五分位数 5 医院的住院和 30 天死亡率风险调整后无显著差异。
在这项队列研究中，具有较高双重资格患者比例的医院在某些关键 HF 护理质量流程措施的实施率较低，并且与较低的双重资格五分位数医院相比，30 天全因或 HF 再入院率较高。
