医疗保险的全面关节置换护理模式增加了公立医院的住院时间。
Medicare's comprehensive care for joint replacement model increased public hospitals' inpatient length of stay.
机构信息
Leonard Davis School of Gerontology, University of Southern California, 3715 McClintock Ave., Los Angeles, CA, 90089, USA.
Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, 635 Downey Way, Los Angeles, CA, 90089, USA.
出版信息
BMC Health Serv Res. 2024 Nov 28;24(1):1495. doi: 10.1186/s12913-024-11905-0.
BACKGROUND
The Comprehensive Care for Joint Replacement (CJR) model is an alternative Medicare payment model for joint replacement that mandated participation by hospitals in randomly selected Metropolitan Statistical Areas (MSAs). On average, the program decreased inpatient length of stay and increased home discharge rates. It is unclear if these effects differed based on hospital ownership type, even though ownership may impact care redesign opportunities.
METHODS
We used the 2014-2017 California Patient Discharge Datasets. The study included 113,590 hospitalizations for hip and knee joint replacement from 287 hospitals in the treated and control MSAs in California. The primary outcomes were inpatient length of stay and home discharge rates. Home discharge status included self-care, the use of home health, and hospice care at home. To determine whether the impact of the CJR model differed by hospital ownership type, we used event study, difference-in-differences (DID), and triple differences (DDD) models to estimate changes in health care services utilization in treated relative to control areas before versus after CJR implementation (April 2016) by hospital ownership type.
RESULTS
Of the 113,590 hospitalizations, 51,708 (45.52%) were in treated MSAs and 61,882 (54.48%) were in control MSAs; 81,649 (71.88%) were from nonprofit hospitals, 20,247 (17.82%) were from for-profit hospitals, and 11,694 (10.29%) were from government-owned hospitals. DID analyses showed that after policy implementation, nonprofit and for-profit hospitals experienced a decrease in inpatient length of stay of 0.02 days (95% CI, -0.04 to -0.01) and 0.04 days (95% CI, -0.06 to -0.01), respectively, while government-owned hospitals experienced an increase by 0.11 days (95% CI, 0.04 to 0.18). For home discharge rates, nonprofit hospitals experienced an increase of 0.02 (95% CI, 0.01 to 0.03), while other hospitals did not show statistically significant changes. DDD analyses confirmed that inpatient length of stay increased in public compared to nonprofit hospitals in treated relative to control MSAs after policy implementation.
CONCLUSIONS
The impacts of the CJR program differed by hospital ownership type. Government-owned hospitals, with their unique financial circumstances, may have faced challenges that hindered the reductions in inpatient length of stay observed in other types of hospitals under the CJR Model.
背景
综合关节置换护理（CJR）模式是一种替代医疗保险支付模式，适用于关节置换，要求医院参与随机选择的大都市统计区（MSA）。平均而言，该计划缩短了住院时间并增加了家庭出院率。尽管所有权可能会影响护理重新设计的机会，但尚不清楚这些影响是否因医院所有权类型而异。
方法
我们使用了 2014-2017 年加利福尼亚患者出院数据集。研究包括来自加利福尼亚治疗和对照 MSA 中 287 家医院的 113590 例髋关节和膝关节置换住院患者。主要结局是住院时间和家庭出院率。家庭出院状态包括自理、家庭保健和家庭临终关怀。为了确定 CJR 模式的影响是否因医院所有权类型而异，我们使用事件研究、差异中的差异（DID）和三重差异（DDD）模型来估计在 CJR 实施前后（2016 年 4 月），按医院所有权类型治疗与对照地区的医疗服务利用变化。
结果
在 113590 例住院患者中，51708 例（45.52%）在治疗 MSA 中，61882 例（54.48%）在对照 MSA 中；81649 例（71.88%）来自非营利性医院，20247 例（17.82%）来自营利性医院，11694 例（10.29%）来自政府所有的医院。DID 分析表明，政策实施后，非营利性和营利性医院的住院时间分别减少了 0.02 天（95%CI，-0.04 至-0.01）和 0.04 天（95%CI，-0.06 至-0.01），而政府所有的医院则增加了 0.11 天（95%CI，0.04 至 0.18）。对于家庭出院率，非营利性医院的出院率增加了 0.02（95%CI，0.01 至 0.03），而其他医院则没有显示出统计学上的显著变化。DDD 分析证实，在政策实施后，治疗 MSA 中公立医院的住院时间比非营利性医院增加。
结论
CJR 计划的影响因医院所有权类型而异。政府所有的医院，由于其独特的财务状况，可能面临挑战，阻碍了 CJR 模式下其他类型医院住院时间的减少。
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