Potentially Avoidable Hospitalizations of Dually Eligible Medicare and Medicaid Beneficiaries from Nursing Facility and Home- and Community-Based Services Waiver Programs
Potentially Avoidable Hospitalizations of Dually Eligible Medicare and Medicaid Beneficiaries from Nursing Facility and Home- and Community-Based Services Waiver Programs
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DOI：
10.1111/j.1532-5415.2012.03920.x
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发表时间：
2012-05-01
影响因子：
6.3
通讯作者：
Ouslander, Joseph G.
中科院分区：
文献类型：
--
作者：
Walsh, Edith G.;Wiener, Joshua M.;Ouslander, Joseph G.
由于医疗保险和医疗补助的临床复杂性和高成本，双重资格的受益人越来越受到关注。本研究的目的是检查该人群中与潜在可避免住院（PAH）相关的发病率、费用和因素。设计：住院患者的回顾性研究。从护理机构（NF）住院，包括医疗保险和医疗补助覆盖的住宿，以及医疗补助家庭和社区服务（HCBS）豁免计划。参与者在2005年接受医疗保险熟练护理设施（SNF）或医疗补助NF服务或HCBS豁免服务的双重符合条件的个人。干预措施。潜在可避免的住院由一个专家小组定义，该小组确定了通常可以预防或无需住院即可安全有效管理的条件和相关诊断相关组（drg）。结果超过三分之一的人口至少住院一次，总计近100万人住院。382,846例（39%）入院患者DRG被确定为PAH。多环芳烃的发病率在各州之间差异很大，黑人的发病率和费用都高于白人。五种情况（肺炎、充血性心力衰竭、尿路感染、脱水和慢性阻塞性肺病/哮喘）导致78%的PAH。这些住院治疗的医疗保险总费用为30亿美元，但医疗补助只有4.63亿美元。一项敏感性分析显示，假设20%-60%的住院治疗是可以预防的，这一人群每年可以避免7.7万至26万次住院治疗和6.25亿至19亿美元的支出。结论：在符合双重条件的人群中，潜在可避免的住院治疗很常见，而且费用高昂。需要采取新的举措来减少这一人群的多环芳烃，因为它们成本高昂，并可能对功能和生活质量产生不利影响。[J]中华医学杂志，2012,31(2):521 - 529。
OBJECTIVES Beneficiaries dually eligible for Medicare and Medicaid are of increasing interest because of their clinical complexity and high costs. The objective of this study was to examine the incidence, costs, and factors associated with potentially avoidable hospitalizations (PAH) in this population.DESIGN Retrospective study of hospitalizations.SETTING Hospitalizations from nursing facilities (NF) including Medicare and Medicaid-covered stays, and Medicaid Home and Community-Based Services (HCBS) waiver programs.PARTICIPANTS Dually eligible individuals who received Medicare skilled nursing facility (SNF) or Medicaid NF services or HCBS waiver services in 2005.INTERVENTIONS None.MEASUREMENTS Potentially avoidable hospitalizations were defined by an expert panel that identified conditions and associated Diagnostic Related Groups (DRGs) which can often be prevented or safely and effectively managed without hospitalization.RESULTS More than one-third of the population was hospitalized at least once, totaling almost 1 million hospitalizations. The admitting DRG for 382,846 (39%) admissions were identified as PAH. PAH rates varied considerably among states, and blacks had a higher rate and costs for PAH than whites. Five conditions (pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease/asthma) were responsible for 78% of the PAH. The total Medicare costs for these hospitalizations were $3 billion, but only $463 million for Medicaid. A sensitivity analysis, assuming that 20%-60% of these hospitalizations could be prevented, revealed that between 77,000 and 260,000 hospitalizations and between $625 million and $1.9 billion in expenditures could be avoided annually in this population.CONCLUSION Potentially avoidable hospitalizations are common and costly in the dually eligible population. New initiatives are needed to reduce PAH in this population as they are costly and can adversely affect function and quality of life. J Am Geriatr Soc 60:821-829, 2012.