Does pay-for-performance improve surgical outcomes? An evaluation of phase 2 of the Premier Hospital Quality Incentive Demonstration.
Does pay-for-performance improve surgical outcomes? An evaluation of phase 2 of the Premier Hospital Quality Incentive Demonstration.
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DOI：
10.1097/sla.0000000000000425
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发表时间：
2014-04
影响因子：
9
通讯作者：
Dimick JB
中科院分区：
文献类型：
--
作者：
Shih T;Nicholas LH;Thumma JR;Birkmeyer JD;Dimick JB
我们试图确定医疗保险的旗舰按绩效付费计划第2阶段的激励设计变化，总理医院质量激励示范（HQID），降低手术死亡率或参与医院的并发症发生率。总理HQID于2003年启动，以奖励表现出色的医院。2006年，该计划重新设计了其激励结构，以奖励取得重大进步的医院。激励结构的变化对手术人群结局的影响尚不清楚。我们检查了2003-2009年12个州（n= 861，411）在医院比较中的高级医院和非高级医院接受冠状动脉搭桥术（CABG）、髋关节置换术和膝关节置换术的患者的出院数据。我们评估了2006年激励结构变化对严重并发症和30天死亡率的影响。在这些分析中，我们使用多元逻辑回归模型调整患者特征。为了说明随着时间的推移结局的改善，我们使用了差异中的差异技术，比较了Premier与非Premier医院的趋势。我们根据风险调整后的死亡率和严重并发症发生率将医院分为五分之一后重复了我们的分析。在2006年对顶级医院的激励措施进行重组后，心脏病和骨科患者的风险调整死亡率和并发症发生率都有所降低。然而，在考虑了非首选医院的时间趋势后，CABG（OR 1.09，95% CI 0.92 - 1.28）或关节置换术（OR 0.81，95% CI 0.58 - 1.12）的死亡率没有显著改善。同样，CABG（OR 1.05，95% CI 0.97 - 1.14）或关节置换术（OR 1.12，95% CI 1.01 - 1.23）的严重并发症也没有显著改善。对激励结构变化中针对的“最差”五分之一医院的分析也没有显示死亡率的变化（CABG组OR 1.01，95% CI 0.78 - 1.32，关节置换组OR 0.96，95% CI 0.22 - 4.26）或严重并发症发生率（CABG的OR 1.08，95% CI 0.88至1.34，OR 0.92，95% CI 0.67至1.28）。尽管最近加强了激励结构，但Premier HQID并未改善参与医院的手术结果。除非进行重大的重新设计，否则按绩效付费可能不是改善手术结果的成功策略。
We sought to determine whether the changes in incentive design in Phase 2 of Medicare’s flagship Pay-for-Performance program, the Premier Hospital Quality Incentive Demonstration (HQID), reduced surgical mortality or complication rates at participating hospitals. The Premier HQID was initiated in 2003 to reward high-performing hospitals. The program redesigned its incentive structure in 2006 to also reward hospitals that achieved significant improvement. The impact of the change in incentive structure on outcomes in surgical populations is unknown. We examined discharge data for patients who underwent coronary artery bypass (CABG), hip replacement, and knee replacement at Premier hospitals and non-Premier hospitals in Hospital Compare from 2003–2009 in 12 states (n=861,411). We assessed the impact of incentive structural changes in 2006 on serious complications and 30-day mortality. In these analyses, we adjusted for patient characteristics using multiple logistic regression models. To account for improvement in outcomes over time, we used difference-in-difference techniques that compare trends in Premier vs. non-Premier hospitals. We repeated our analyses after stratifying hospitals into quintiles according to risk-adjusted mortality and serious complication rates. After restructuring incentives in 2006 in Premier hospitals, there were lower risk-adjusted mortality and complication rates for both cardiac and orthopedic patients. However, after accounting for temporal trends in non-Premier hospitals, there were no significant improvements in mortality for CABG (OR 1.09, 95% CI 0.92 to 1.28) or joint replacement (OR 0.81, 95% CI 0.58 to 1.12). Similarly, there were no significant improvements in serious complications for CABG (OR 1.05, 95% CI 0.97 to 1.14) or joint replacement (OR 1.12, 95% CI 1.01 to 1.23). Analysis of the “worst” quintile hospitals that were targeted in the incentive structural changes also did not reveal a change in mortality (OR 1.01, 95% CI 0.78 to 1.32 for CABG and OR 0.96, 95% CI 0.22 to 4.26 for joint replacement) or serious complication rates (OR 1.08, 95% CI 0.88 to 1.34 for CABG and OR 0.92, 95% CI 0.67 to 1.28). Despite recent enhancements to incentive structures, the Premier HQID did not improve surgical outcomes at participating hospitals. Unless significantly redesigned, pay-for-performance may not be a successful strategy to improve outcomes in surgery.