Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions
Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions
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DOI：
10.1001/jama.2016.18533
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发表时间：
2016-12-27
影响因子：
120.7
通讯作者：
Horwitz, Leora I.
中科院分区：
文献类型：
--
作者：
Desai, Nihar R.;Ross, Joseph S.;Horwitz, Leora I.
重要性医院再入院减少计划（HRRP）宣布后，再入院率下降，该计划对急性心肌梗死（AMI）、心力衰竭（HF）和肺炎的过度再入院进行惩罚。对2008年1月1日至2015年6月30日期间出院的64岁以上医疗保险按服务收费受益人进行的回顾性队列研究，2214家罚款医院和1283家非罚款医院。差异中断的时间序列模型被用来比较的条件和处罚status.EXPOSURE医院处罚状态或目标条件下的HRRP.MAIN结果和措施的再入院率的趋势30天的风险调整，全因计划外再入院率为目标和非目标conditions.RESULTS研究包括48 137 102住院的20 351 161医疗保险受益人。2008年1月，AMI、HF、肺炎和非目标疾病的平均再入院率分别为21.9%、27.5%、20.1%和18.4%，在后来受到经济处罚的医院，分别为18.7%、24.2%、17.4%和15.7%。2008年1月至2010年3月，在HRRP宣布之前，各医院的再入院率稳定（非惩罚性医院的AMI除外）。HRRP发布后（2010年3月），目标和非目标条件的再入院率下降明显更快的医院后，受到经济处罚的医院相比，那些在非处罚医院（对于AMI，相对于非惩罚性排放，每年额外降低-1.24 [95%CI，-1.84 to -0.65]个百分点;对于HF，-0.25 [95%CI，-1.64至-0.86];对于肺炎，-1.37 [95%CI，-1.80至-0.95];对于非靶向条件，-0.27 [95%CI，-0.38至-0.17]; P均<0.001）。对于惩罚性医院，目标条件的再入院率与非目标条件相比下降得更快（AMI患者，相对于非目标条件，每年额外下降-0.49 [95%CI，-0.81至-0.16]个百分点[P = .004]; HF患者，-0.90 [95%CI，-1.18至-0.62; P < .001];肺炎为-0.57 [95%CI，-0.92至-0.23; P < .001]）。相比之下，在非惩罚性医院中，与非目标条件相比，目标条件的再入院率下降相似或更慢（对于AMI，每年额外增加0.48 [95% CI，0.01-0.95]个百分点[P = 0.05];对于HF，0.08 [95% CI，-0.30至0.46; P = 0.67];对于肺炎，0.53 [95% CI，0.13-0.93; P = .01]）。2012年10月实施HRRP后，再入院率的变化率趋于平稳（P < .05，除肺炎在nonpenalty hospitals），与最大的相对变化之间观察到的医院受到财政penalty.CONCLUSIONS AND RELEVANCE医疗保险收费服务的患者在医院受到HRRP下的处罚有更大的减少再入院率相比，在nonpenalized hospitals。受处罚医院的患者目标与非目标条件的变化更大，但在其他医院则不然。
IMPORTANCE Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.OBJECTIVE To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status.DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008, and June 30, 2015, from 2214 penalty hospitals and 1283 nonpenalty hospitals. Difference-interrupted time-series models were used to compare trends in readmission rates by condition and penalty status.EXPOSURE Hospital penalty status or target condition under the HRRP.MAIN OUTCOMES AND MEASURES Thirty-day risk adjusted, all-cause unplanned readmission rates for target and nontarget conditions.RESULTS The study included 48 137 102 hospitalizations of 20 351 161 Medicare beneficiaries. In January 2008, the mean readmission rates for AMI, HF, pneumonia, and nontarget conditions were 21.9%, 27.5%, 20.1%, and 18.4%, respectively, at hospitals later subject to financial penalties and 18.7%, 24.2%, 17.4%, and 15.7% at hospitals not subject to penalties. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of -1.24 [95% CI, -1.84 to -0.65] percentage points per year relative to nonpenalty discharges; for HF, -.25 [95% CI, -1.64 to -0.86]; for pneumonia, -1.37 [95% CI, -1.80 to -0.95]; and for nontarget conditions, -0.27 [95% CI, -0.38 to -0.17]; P < .001 for all). For penalty hospitals, readmission rates for target conditions declined significantly faster compared with nontarget conditions (for AMI, additional decline of -0.49 [95% CI, -0.81 to -0.16] percentage points per year relative to nontarget conditions [P = .004]; for HF, -0.90 [95% CI, -1.18 to -0.62; P < .001]; and for pneumonia, -0.57 [95% CI, -0.92 to -0.23; P < .001]). In contrast, among nonpenalty hospitals, readmissions for target conditions declined similarly or more slowly compared with nontarget conditions (for AMI, additional increase of 0.48 [95% CI, 0.01-0.95] percentage points per year [P = .05]; for HF, 0.08 [95% CI, -0.30 to 0.46; P = .67]; for pneumonia, 0.53 [95% CI, 0.13-0.93; P = .01]). After HRRP implementation in October 2012, the rate of change for readmission rates plateaued (P < .05 for all except pneumonia at nonpenalty hospitals), with the greatest relative change observed among hospitals subject to financial penalty.CONCLUSIONS AND RELEVANCE Medicare fee-for-service patients at hospitals subject to penalties under the HRRP had greater reductions in readmission rates compared with those at nonpenalized hospitals. Changes were greater for target vs nontarget conditions for patients at the penalized hospitals but not at the other hospitals.