Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study
Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study
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DOI：
10.1136/bmj.l4109
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发表时间：
2019-07-03
影响因子：
105.7
通讯作者：
Ryan, Andrew M.
中科院分区：
文献类型：
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作者：
Sankaran, Roshun;Sukul, Devraj;Ryan, Andrew M.
目的评估美国医院获得性疾病减少计划（HACCP）中的医院处罚与临床结局的后续变化之间的关系。将非连续性回归设计应用于来自住院医疗保险索赔的回顾性队列。在美国设置3238家急性护理医院。2014年7月23日至2016年11月30日期间从急症护理医院出院的服务受益人，并且符合至少一种目标医院获得性疾病的资格（n= 15470334）.干预医院在实施HACCP的第一年中收到的惩罚.主要结果测量每1000次发作中目标医院获得性疾病的类型水平计数，30天再入院，在2015财政年度根据HACCP处罚的724家医院中，有708家医院参与了这项研究。受处罚医院的平均医院获得性疾病计数为2.72/1000次发作，非受处罚医院为2.06/1000次发作;两个医院组的30天再入院率分别为14.4%和14.0%，30天死亡率为9.0%。与未受处罚的医院相比，受处罚的医院更有可能是大型教学机构，并且社会经济地位较低的患者所占比例更大。HACCP惩罚与每1000次发作-0.16医院获得性疾病（95%置信区间-0.53至0.20）、30天再入院率-0.36个百分点（-1.06至0.33）和30天死亡率-0.04个百分点（-0.59至0.52）的非显著变化相关。没有明确的模式，临床改善被观察到整个hospital characteristics.CONCLUSIONSPenalization是不相关的显着变化率的医院获得性条件，30天再入院，或30天死亡率，并没有出现驱动有意义的临床改善。通过不成比例地惩罚照顾弱势患者的医院，HACCP可能会加剧护理的不公平。
OBJECTIVE To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes.DESIGNRegression discontinuity design applied to a retrospective cohort from inpatient Medicare claims.SETTING3238 acute care hospitals in the United States.PARTICIPANTSMedicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334).INTERVENTIONHospital receipt of a penalty in the first year of the HACRP.MAIN OUTCOME MEASURESEpisode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality.RESULTSOf 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of -0.16 hospital acquired conditions per 1000 episodes (95% confidence interval -0.53 to 0.20), -0.36 percentage points in 30 day readmission (-1.06 to 0.33), and -0.04 percentage points in 30 day mortality (-0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics.CONCLUSIONSPenalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.