Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery
Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery
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DOI：
10.1097/mlr.0000000000001052
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发表时间：
2019-03-01
期刊：
影响因子：
3
通讯作者：
Hollingsworth, John M.
中科院分区：
文献类型：
--
作者：
Kim, Dennie;Funk, Russell J.;Hollingsworth, John M.
背景资料：责任医疗组织（ACO）专注于正式的临床整合，以改善结果，忽视了围绕共享患者的提供者互动的实际模式。目的：确定这种非正式的临床整合是否与ACO中卫生系统的绩效有关。研究设计：我们分析了国家医疗保险数据（2008-2014），确定了接受冠状动脉旁路移植术（CABG）的受益人。在确定哪些医生向他们提供护理后，我们汇总了各个事件，为每个卫生系统构建了医生网络。我们使用网络分析来衡量每个系统的非正式临床整合水平（由跨专业关系定义）。我们拟合回归模型，以检查卫生系统的CABG死亡率和ACO参与之间的关联，条件是非正式的临床整合。受试者：接受CABG的66岁及以上受益人。测量：90天CABG死亡率。结果：在研究期间，3385名受益人在161个参加卫生系统的ACO中接受治疗。其余49，854例患者在ACO开始日期之前在875个非参与系统或161个ACO参与系统之一中接受治疗。非正式临床整合水平较高的ACO系统的CABG死亡率低于未参与的ACO系统（2.8% vs 5.5%; P< 0.01）;然而，基于ACO参与程度，非正式临床整合水平较低至相对中度的卫生系统之间没有差异。回归结果证实了这一发现（ACO参与和非正式临床整合水平之间的相互作用系数为-0.25; P= 0.01）。结论：通过ACO参与的正式临床整合可能不足以改善结局。非正式临床整合程度较高的卫生系统可能会从ACO的参与中受益更多。
Background: Accountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients. Objective: To determine whether such informal clinical integration relates to a health system's performance in an ACO. Research Design: We analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physicians delivered care to them, we aggregated across episodes to construct physician networks for each health system. We used network analysis to measure each system's level of informal clinical integration (defined by cross-specialty ties). We fit regression models to examine the association between a health system's CABG mortality rate and ACO participation, conditional on informal clinical integration. Subjects: Beneficiaries age 66 and older undergoing CABG. Measures: Ninety-day CABG mortality. Results: Over the study period, 3385 beneficiaries were treated in 161 ACO-participating health systems. The remaining 49,854 were treated in 875 nonparticipating systems or one of the 161 ACO-participating systems before the ACO start date. ACO systems with higher levels of informal clinical integration had lower CABG mortality rates than nonparticipating ones (2.8% versus 5.5%; P< 0.01); however, there was no difference based on ACO participation for health systems with lower to relatively moderate informal clinical integration. Regression results corroborate this finding (coefficient for interaction between ACO participation and informal clinical integration level is -0.25; P= 0.01). Conclusions: Formal clinical integration through ACO participation may be insufficient to improve outcomes. Health systems with higher informal clinical integration may benefit more from ACO participation.