Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.
J Palliat Med. 2022 Dec;25(12):1795-1801. doi: 10.1089/jpm.2022.0047. Epub 2022 Jun 8.
Medicare alternative payment models were created to improve health care value by controlling costs and improving care quality. To determine if prevalence of pain affecting quality of life (QoL) differs by Medicare payment model among nursing home (NH) decedents with dementia at the end of life. NH decedents in 2017/2018 in the United States with dementia who self-reported pain on a Minimum Data Set assessment in the last 30 days of life. Main outcome was pain impacting QoL (i.e., affecting day-to-day activities or sleep). Multivariable logistic analysis examined the association between payment model (traditional Medicare [TM], Medicare Advantage [MA], or accountable care organizations [ACOs]) and pain impacting QoL after controlling for potential confounders. There were 115,757 NH residents with dementia who self-reported pain in the last 30 days of life. Of those, 17.8% ( = 20,585) reported having pain the last five days from assessment, which varied by Medicare payment model (17.7% in TM, 17.5% in MA, and 19.1% in ACOs; < 0.001). Among decedents reporting pain, 23.6% of ACO decedents reported pain affecting QoL compared to 22.1% in MA and 21.6% in TM ( = 0.09). After adjustment, decedents in ACOs compared to TM had greater predicted probability of pain affecting QoL (absolute marginal difference 0.017, 95% CI 0.00-0.035, = 0.05), and persons in MA did not differ from persons in TM (absolute marginal difference 0.005, 95% CI -0.008 to 0.019, = 0.41). Among dementia decedents dying with pain, pain impacted QoL in more than one in five persons. All payment models can improve pain management.
医疗保险替代支付模式的创建旨在通过控制成本和提高医疗质量来提高医疗保健的价值。为了确定在生命末期患有痴呆症的养老院（NH）死者中，医疗保险支付模式是否会影响疼痛对生活质量（QoL）的影响。2017/2018 年在美国，NH 死者患有痴呆症，在生命的最后 30 天内自我报告疼痛。主要结果是疼痛影响 QoL（即，影响日常活动或睡眠）。多变量逻辑分析检查了支付模式（传统医疗保险[TM]，医疗保险优势[MA]或问责制医疗组织[ACO]）与控制潜在混杂因素后疼痛影响 QoL 之间的关联。有 115,757 名 NH 居民患有痴呆症，他们在生命的最后 30 天内自我报告疼痛。其中，17.8%（=20,585）报告说在评估的最后五天有疼痛，这因医疗保险支付模式而异（TM 为 17.7%，MA 为 17.5%，ACO 为 19.1%；<0.001）。在报告疼痛的死者中，ACO 死者中有 23.6%的人报告疼痛影响 QoL，而 MA 中有 22.1%，TM 中有 21.6%（=0.09）。调整后，与 TM 相比，ACO 中的死者疼痛影响 QoL 的预测概率更高（绝对边际差异 0.017，95%CI 0.00-0.035，=0.05），而 MA 中的死者与 TM 中的死者没有差异（绝对边际差异 0.005，95%CI -0.008 至 0.019，=0.41）。在患有疼痛并死亡的痴呆症死者中，超过五分之一的人疼痛影响 QoL。所有支付模式都可以改善疼痛管理。
