Harvard University Graduate School of Arts and Sciences, Boston, Massachusetts.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
JAMA Health Forum. 2024 Apr 5;5(4):e240678. doi: 10.1001/jamahealthforum.2024.0678.
Two in 5 US hospital stays result in rehabilitative postacute care, typically through skilled nursing facilities (SNFs) or home health agencies (HHAs). However, a lack of clear guidelines and understanding of patient and caregiver preferences make it challenging to promote high-value patient-centered care.
To assess preferences and willingness to pay for facility-based vs home-based postacute care among patients and caregivers, considering demographic variations.
DESIGN, SETTING, AND PARTICIPANTS: In September 2022, a nationally representative survey was conducted with participants 45 years or older. Using a discrete choice experiment, participants acting as patients or caregivers chose between facility-based and home-based postacute care that best met their preferences, needs, and family conditions. Survey weights were applied to generate nationally representative estimates.
Preferences and willingness to pay for various attributes of postacute care settings were assessed, examining variation based on demographic factors, socioeconomic status, job security, and previous care experiences.
A total of 2077 adults were invited to participate in the survey; 1555 (74.9%) completed the survey. In the weighted sample, 52.9% of participants were women, 6.5% were Asian or Pacific Islander, 1.7% were American Indian or Alaska Native, 11.2% were Black or African American, 78.4% were White; the mean (SD) age was 62.6 (9.6) years; and there was a survey completion rate of 74.9%. Patients and caregivers showed a substantial willingness to pay for home-based and high-quality care. Patients and caregivers were willing to pay an additional $58.08 per day (95% CI, 45.32-70.83) and $45.54 per day (95% CI, 31.09-59.99) for HHA care compared with a shared SNF room, respectively. However, increased demands on caregiver time within an HHA scenario and socioeconomic challenges, such as insecure employment, shifted caregivers' preferences toward facility-based care. There was a strong aversion to below average quality. To avoid below average SNF care, patients and caregivers were willing to pay $75.21 per day (95% CI, 61.68-88.75) and $79.10 per day (95% CI, 63.29-94.91) compared with average-quality care, respectively. Additionally, prior awareness and experience with postacute care was associated with willingness to pay for home-based care. No differences in preferences among patients and caregivers based on race, educational background, urban or rural residence, general health status, or housing type were observed.
The findings of this survey study underscore a prevailing preference for home-based postacute care, aligning with current policy trends. However, attention is warranted for disadvantaged groups who are potentially overlooked during the shift toward home-based care, particularly those facing caregiver constraints and socioeconomic hardships. Ensuring equitable support and improved quality measure tools are crucial for promoting patient-centric postacute care, with emphasis on addressing the needs of marginalized groups.
在美国，有五分之二的住院患者需要接受康复性的急性后期护理，通常是通过熟练护理设施（SNFs）或家庭保健机构（HHAs）来实现。然而，由于缺乏明确的指导方针和对患者及照护者偏好的理解，因此难以促进以患者为中心的高价值医疗服务。
评估患者和照护者对基于设施和基于家庭的急性后期护理的偏好和支付意愿，并考虑人口统计学差异。
设计、地点和参与者：在 2022 年 9 月，对 45 岁或以上的人群进行了一项全国代表性的调查。使用离散选择实验，参与者作为患者或照护者在最能满足其偏好、需求和家庭条件的基于设施和基于家庭的急性后期护理之间进行选择。调查权重被应用于生成全国代表性的估计值。
评估了急性后期护理环境的各种属性的偏好和支付意愿，考察了基于人口统计学因素、社会经济地位、工作保障和以前的护理经验的变化。
共邀请了 2077 名成年人参与调查；1555 人（74.9%）完成了调查。在加权样本中，52.9%的参与者为女性，6.5%为亚裔或太平洋岛民，1.7%为美国印第安人或阿拉斯加原住民，11.2%为黑人或非裔美国人，78.4%为白人；平均（SD）年龄为 62.6（9.6）岁；调查完成率为 74.9%。患者和照护者表现出对家庭护理和高质量护理的强烈支付意愿。与共享 SNF 房间相比，患者和照护者分别愿意每天多支付 58.08 美元（95%CI，45.32-70.83）和 45.54 美元（95%CI，31.09-59.99）用于 HHA 护理。然而，HHA 场景中对照护者时间的需求增加以及就业不稳定等社会经济挑战，使照护者更倾向于选择基于设施的护理。患者和照护者强烈反对低于平均水平的服务质量。为了避免低于平均水平的 SNF 护理，患者和照护者愿意每天多支付 75.21 美元（95%CI，61.68-88.75）和 79.10 美元（95%CI，63.29-94.91）用于接受高质量护理。此外，对急性后期护理的事先了解和经验与支付家庭护理的意愿有关。没有观察到患者和照护者之间基于种族、教育背景、城市或农村居住、总体健康状况或住房类型的偏好差异。
这项调查研究的结果强调了对家庭为基础的急性后期护理的普遍偏好，这与当前的政策趋势一致。然而，需要关注那些在向家庭为基础的护理转变过程中可能被忽视的弱势群体，特别是那些面临照护者限制和社会经济困难的群体。确保为以患者为中心的急性后期护理提供公平的支持和改进的质量衡量工具至关重要，重点是解决边缘化群体的需求。
