Nonpayment for Preventable Complications: Impact on Hospital Practices and Health

描述（由申请人提供）：经济激励措施，例如按绩效付费（P4P）计划，越来越多地用于改善医生行为。然而，这些计划对提高患者护理质量的影响参差不齐，一些研究显示效果有限，而另一些研究则报告护理质量措施几乎没有改善。此外，P4P 计划的意外后果也已被证明，包括对基线绩效较高的医院给予更大的经济奖励，以及为大量少数族裔人口服务的医院造成重大经济损失。从2008年10月1日起，Medicare将实施使用新的财务机制——可预防并发症不付费（NPPC）——这是一根“大棒”而不是“胡萝卜”。如果患者入院时不在场，医疗保险将不再向医院支付治疗某些医疗相关感染 (HAI) 的费用。我们提出的研究是独特且及时的。目前还没有关于美国最大支付者之一正在实施的 NPPC 政策干预措施的影响的数据。尽管缺乏证据证明其有效性，但希望财务抑制措施将激励医院和医疗服务提供者集中精力减少医院感染。虽然目标当然是有价值的，但应该严格评估用于激励变革的机制，以确保其实现预期结果，而不会发生意外后果。我们的研究将深入了解 NPPC 对患者护理和结果的潜在影响，包括积极和消极的影响。该提案的长期目标是评估 NPPC 对患者护理和结果的总体影响。在这项两阶段的研究中，我们将首先进行定性访谈，以确定可能影响医院实践和 HAI 发生率的关键因素。在第二阶段，我们将根据我们的定性研究结果开发、试点和验证一个调查工具，以便对感染预防人员进行未来的调查，以评估 NPPC 对美国医院的影响。因此，我们提出以下具体目标： 1. 确定可能影响 NPPC 背景下感染预防实践的关键因素。 2. 开发、试点和验证一项调查工具，以检验 NPPC 对医院行为和实践的感知影响。公共卫生相关性：美国医院每年发生大约 1.7 至 200 万例医疗保健相关感染 (HAI) 和 99,000 例 HAI 导致的死亡。 HAI 每年的经济负担估计为 17 至 290 亿美元。我们提出的研究将提供有关 Medicare 对可预防并发症不付款的做法（即减少与 HAI 相关的住院报销）对护理质量和健康结果的影响的重要信息。

DESCRIPTION (provided by applicant): Financial incentives, such as pay-for-performance (P4P) programs, are increasingly being used to improve physician behavior. However, the impact of these programs on improving quality of care for patients have been mixed, with some studies showing modest gains and others reporting little to no improvement on quality of care measures. Furthermore, unintended consequences of P4P programs have been demonstrated, including larger financial rewards for those hospitals with higher performance at baseline and significant financial losses for hospitals that serve large minority populations. As of October 1, 2008, Medicare will implement the use of a new financial mechanism-nonpayment for preventable complications (NPPC)-which is a "stick" rather than a "carrot". Medicare will no longer pay hospitals for treating certain healthcare associated infections (HAIs) that arise in patients if they are not present on admission. Our proposed research is unique and timely. There are no data available on the impact of a NPPC policy intervention that is being implemented by one of the largest payers in the U.S. Despite lack of evidence for its efficacy, it is hoped that financial disincentives will motivate hospitals and providers to focus their efforts on reducing HAIs. While the goal is certainly worthy, the mechanism being used to motivate change should be rigorously evaluated to ensure that it achieves its intended consequences without the occurrence of unintended consequences. Our research will provide a rich understanding of the potential impact, both positive and negative, of NPPC on patient care and outcomes. The long-term goal of this proposal is to assess the overall impact NPPC on patient care and outcomes. In this two-phase study, we will first conduct qualitative interviews to identify key elements that may affect hospital practices and rates of HAIs. In the second phase, we will develop, pilot, and validate a survey instrument based on our qualitative research findings in order to conduct a future survey of infection preventionists to assess the perceived impact of NPPC on hospitals in the U.S. Thus, we propose the following specific aims: 1. To identify key factors that may affect infection prevention practices in the context of NPPC. 2. To develop, pilot, and validate a survey instrument to examine the perceived impact of NPPC on behaviors and practices in hospitals. PUBLIC HEALTH RELEVANCE: Approximately 1.7 to 2 million healthcare-associated infections (HAIs) and 99,000 deaths due to HAIs occur in U.S. hospitals annually. The economic burden of HAIs is estimated at $17 to $29 billion dollars each year. Our proposed study will provide crucial information regarding the impact of Medicare's use of nonpayment for preventable complications (i.e. reduced reimbursement for hospitalizations associated with HAIs) on quality of care and health outcomes.