Factors Associated With Disparities in Hospital Readmission Rates Among US Adults Dually Eligible for Medicare and Medicaid.
Factors Associated With Disparities in Hospital Readmission Rates Among US Adults Dually Eligible for Medicare and Medicaid.
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DOI：
10.1001/jamahealthforum.2021.4611
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发表时间：
2022-01
期刊：
影响因子：
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通讯作者：
Bernheim S
中科院分区：
文献类型：
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作者：
Silvestri D;Goutos D;Lloren A;Zhou S;Zhou G;Farietta T;Charania S;Herrin J;Peltz A;Lin Z;Bernheim S
州和社区层面的因素在多大程度上与符合双重资格的 Medicare 患者再入院的院内差异相关？在这项针对 250 万 65 岁或以上美国成年人的队列研究中，在考虑了州和社区层面的社会和卫生服务可用性因素后，双重资格患者 30 天再入院的院内差异仍然存在。当纳入社区层面因素的调整后，医院排名或医院绩效差异之间没有发生有意义的变化。社区层面因素的差异不能完全解释医院对双重资格患者 30 天再入院率的差异，这种持续的变化表明医院有继续努力促进医疗保健结果公平性的机会。这项队列研究探讨了州和社区层面的因素与具有双重资格的医疗保险患者的医院内再入院率差异的相关程度。具有医疗保险和医疗补助双重资格 (DE) 的低收入老年人在住院后往往会经历更糟糕的结果。在旨在改善 DE 患者健康的其他联邦政策中，医疗保险最近开始报告院内再入院的差异。 DE 患者的差异在多大程度上是由于社区层面因素的差异造成的，或者相反，是由于医院质量的提高而导致的，仍然存在激烈的争论。研究州和社区层面的因素在多大程度上改善了 DE 患者 30 天再入院率的院内差异。在这项回顾性队列研究中，医疗保险和医疗补助服务中心 (CMS) 差异方法用于计算参与医疗保险的美国医院中 DE 与非 DE 患者的 30 天风险调整再入院率的院内差异。所有分析均于 2019 年 2 月和 3 月进行。该研究包括 2014 年至 2017 年因急性心肌梗死 (AMI)、心力衰竭 (HF) 或肺炎住院的 Medicare 患者（年龄≥65 岁）。院内差异，以因 AMI、HF 或肺炎入院后 30 天再入院率差异 (RD) 来衡量 DE 患者与非 DE 患者之间的差异；各医院之间存在差异；以及医院 RD 的相关性，无论是否根据州医疗补助资格政策和社区层面的因素进行调整。最终样本包括 475±444 名因 AMI 入院的患者、898±395 名因 HF 入院的患者和 1±214±282 名因肺炎入院的患者，其中 DE 患者分别占 13.2%、17.4% 和 23.0%。在美国医院中，99.0% (AMI)、99.4% (HF) 和 97.5% (肺炎) 的双重合格患者的 30 天再入院率高于非 DE 患者 (RD >0)。在各医院中，AMI 与非 DE 之间的平均 (IQR) RD 为 1.00% (0.87%-1.10%)，HF 为 0.82% (0.73%-0.96%)，肺炎为 0.53% (0.37%-0.71%)。调整社区层面因素后，AMI 的平均 (IQR) RD 为 0.87% (0.73%-0.97%)，HF 为 0.67% (0.57%-0.80%)，肺炎为 0.42% (0.29%-0.57%)。社区级别调整前后相应院内差异的相对医院排名高度相关（皮尔逊系数，0.98）。在这项队列研究中，DE 患者 30 天再入院的院内差异与州医疗补助政策和社区层面因素的差异有一定关系。这表明，这些差异中的剩余差异应该成为医院努力提高 DE 患者出院护理过渡质量的重点，以促进公平。
To what extent are state- and community-level factors associated with within-hospital disparities in hospital readmission for dual-eligible Medicare patients? In this cohort study of 2.5 million US adults aged 65 years or older, within-hospital disparities in 30-day readmission for dual-eligible patients persisted after accounting for state- and community-level social and health service availability factors. There was no meaningful change in hospital ranking or between hospital variation in disparity performance when adjustments for community-level factors were included. Hospital disparities in 30-day readmission rates for dual-eligible patients are not fully explained by differences in community-level factors, and this persistent variation suggests continued opportunities for hospital efforts to advance equity in health care outcomes. This cohort study examines the extent to which state- and community-level factors are associated with within-hospital disparities in hospital readmission rates for dual-eligible Medicare patients. Low-income older adults who are dually eligible (DE) for Medicare and Medicaid often experience worse outcomes following hospitalization. Among other federal policies aimed at improving health for DE patients, Medicare has recently begun reporting disparities in within-hospital readmissions. The degree to which disparities for DE patients are owing to differences in community-level factors or, conversely, are amenable to hospital quality improvement, remains heavily debated. To examine the extent to which within-hospital disparities in 30-day readmission rates for DE patients are ameliorated by state- and community-level factors. In this retrospective cohort study, Centers for Medicare & Medicaid Services (CMS) Disparity Methods were used to calculate within-hospital disparities in 30-day risk-adjusted readmission rates for DE vs non-DE patients in US hospitals participating in Medicare. All analyses were performed in February and March 2019. The study included Medicare patients (aged ≥65 years) hospitalized for acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2014 to 2017. Within-hospital disparities, as measured by the rate difference (RD) in 30-day readmission between DE vs non-DE patients following admission for AMI, HF, or pneumonia; variance across hospitals; and correlation of hospital RDs with and without adjustment for state Medicaid eligibility policies and community-level factors. The final sample included 475 444 patients admitted for AMI, 898 395 for HF, and 1 214 282 for pneumonia, of whom 13.2%, 17.4%, and 23.0% were DE patients, respectively. Dually eligible patients had higher 30-day readmission rates relative to non-DE patients (RD >0) in 99.0% (AMI), 99.4% (HF), and 97.5% (pneumonia) of US hospitals. Across hospitals, the mean (IQR) RD between DE vs non-DE was 1.00% (0.87%-1.10%) for AMI, 0.82% (0.73%-0.96%) for HF, and 0.53% (0.37%-0.71%) for pneumonia. The mean (IQR) RD after adjustment for community-level factors was 0.87% (0.73%-0.97%) for AMI, 0.67% (0.57%-0.80%) for HF, and 0.42% (0.29%-0.57%) for pneumonia. Relative hospital rankings of corresponding within-hospital disparities before and after community-level adjustment were highly correlated (Pearson coefficient, 0.98). In this cohort study, within-hospital disparities in 30-day readmission for DE patients were modestly associated with differences in state Medicaid policies and community-level factors. This suggests that remaining variation in these disparities should be the focus of hospital efforts to improve the quality of care transitions at discharge for DE patients in efforts to advance equity.