Nonpayment for Preventable Complications: Impact on Hospital Practices and Health

描述（由申请人提供）：财务激励，如绩效薪酬（P4P）计划，越来越多地被用于改善医生的行为。然而，这些项目对提高患者护理质量的影响参差不齐，一些研究显示出适度的收益，而另一些研究则报告在护理质量方面几乎没有改善。此外，P4P项目的意想不到的后果已经被证明，包括那些在基线上表现较高的医院获得了更大的经济回报，而为大量少数民族人口服务的医院则遭受了重大的经济损失。从2008年10月1日起，医疗保险将实施一种新的金融机制——可预防并发症不付款（NPPC）——这是一种“大棒”而不是“胡萝卜”。医疗保险将不再支付医院治疗某些医疗保健相关感染（HAIs），如果患者在入院时不存在。我们提出的研究是独特和及时的。美国最大的付款人之一正在实施的NPPC政策干预的影响尚无数据，尽管缺乏其有效性的证据，但希望财政激励将激励医院和提供者集中精力减少HAIs。虽然目标肯定是值得的，但是用于激励变化的机制应该被严格地评估，以确保它达到预期的结果，而不会出现意想不到的结果。我们的研究将为NPPC对患者护理和结果的潜在影响提供丰富的理解，无论是积极的还是消极的。本提案的长期目标是评估NPPC对患者护理和结果的总体影响。在这个两阶段的研究中，我们将首先进行定性访谈，以确定可能影响医院实践和高质量医疗服务比率的关键因素。在第二阶段，我们将根据我们的定性研究结果开发、试点和验证一种调查工具，以便对感染预防学家进行未来的调查，以评估NPPC对美国医院的感知影响。因此，我们提出以下具体目标：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，以检查NPPC对医院行为和实践的感知影响。公共卫生相关性：美国医院每年约有170万至200万卫生保健相关感染（HAIs）和99,000例因HAIs死亡。据估计，艾滋病患者每年的经济负担在170亿至290亿美元之间。我们提出的研究将提供关于医疗保险对可预防并发症不付款的影响的关键信息（即减少与HAIs相关的住院费用报销）对护理质量和健康结果的影响。

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.