在医疗保险优势计划、问责制医疗组织或传统医疗保险中，患有痴呆症的人去世。
Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare.
机构信息
Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
出版信息
J Am Geriatr Soc. 2021 Oct;69(10):2802-2810. doi: 10.1111/jgs.17225. Epub 2021 May 14.
BACKGROUND/OBJECTIVE: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM).
DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment.
MEASUREMENTS
Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing.
RESULTS
Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM.
CONCLUSIONS
Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.
背景/目的：医疗保险优势计划（MA）和问责制医疗组织（ACO）的运营旨在减少生命末期繁重和昂贵的护理。我们比较了参加 MA、ACO 或传统医疗保险（TM）的痴呆症患者的临终护理。
设计、地点和参与者：对在 MA、归因于 ACO 或 TM 中患有痴呆症的死者进行回顾性研究。死者在死前有 91 至 180 天的疗养院住宿、两种或多种功能障碍和轻度至重度认知障碍。
测量
医疗保险计费中报告的生命最后 30 天内的住院治疗、有创机械通气（IMV）使用和院内死亡。
结果
在 370094 名患有痴呆症的患者中，93801 名（25.4%）参加了 MA（平均年龄[标准差]，86.9[7.7]，67.6%为女性），39586 名（10.7%）归因于 ACO（平均年龄[标准差]，87.2[7.6]，67.3%为女性），236707 名（63.9%）参加了 TM（平均年龄[标准差]，87.0[7.8]，67.6%为女性）。在生命最后 30 天住院的比例在 TM 参保者（27.9%）和归因于 ACO 的参保者（28.1%）中高于 MA 参保者（20.5%，p≤0.001）。调整社会人口统计学、认知和功能障碍、合并症和医院转诊区后，与 TM 参保者相比，MA 参保者在死亡前 30 天住院的调整后优势比为 0.72（95%置信区间[CI]0.70-0.74），归因于 ACO 的参保者为 1.05（95%CI1.02-1.09）。与 TM 相比，MA 参保者在医院死亡的调整后优势比为 0.78（95%CI0.75-0.81），归因于 ACO 的参保者为 1.02（95%CI0.96-1.08）。与 TM 相比，MA 参保者使用呼吸机的可能性较低（调整后的优势比为 0.80，95%CI0.75-0.85）。
结论
在患有痴呆症的死者中，与 TM 相比，MA 参保者而非 ACO 中的死者经历的护理费用更低，潜在负担也更小。需要对 ACO 进行政策改革。
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