Nonpayment for Preventable Complications: Impact on Hospital Practices and Health

描述(由申请人提供)：财政激励，如绩效工资(P4P)计划，正越来越多地被用于改善医生的行为。然而，这些计划对提高患者护理质量的影响是喜忧参半的，一些研究显示略有改善，另一些研究报告在护理质量措施方面几乎没有改善。此外，已经证明了P4P计划的意外后果，包括为那些在基线上表现更好的医院提供更大的经济奖励，以及为大量少数族裔人口服务的医院遭受重大经济损失。从2008年10月1日起，联邦医疗保险将实施一种新的财务机制--可预防并发症不付费(NPPC)--这是一根“大棒”，而不是“胡萝卜”。如果患者在入院时不在场，联邦医疗保险将不再向治疗某些医疗相关感染(HAI)的医院支付费用。我们提出的研究是独一无二的，也是及时的。美国最大的支付者之一正在实施NPPC政策干预，目前还没有关于其影响的数据。尽管缺乏其有效性的证据，但人们希望财政抑制措施将激励医院和提供者将努力集中在减少HAIS上。虽然这一目标肯定是值得的，但应该严格评估用来推动变革的机制，以确保它实现预期的结果，而不发生意想不到的后果。我们的研究将对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。这项提案的长期目标是评估NPPC对患者护理和结果的总体影响。在这项分两个阶段进行的研究中，我们将首先进行定性访谈，以确定可能影响医院做法和医院感染比率的关键因素。在第二阶段，我们将根据我们的定性研究结果开发、试行和验证调查工具，以便对感染预防人员进行未来的调查，以评估NPPC对美国医院的感知影响。因此，我们提出以下具体目标：1.在NPPC的背景下确定可能影响感染预防实践的关键因素。2.开发、试行和验证调查工具，以检验NPPC对医院行为和实践的感知影响。公共卫生相关性：美国医院每年大约发生170至200万例与医疗保健相关的感染(HAI)，并有99,000人死于HAIs。据估计，HAIS每年造成的经济负担为170亿至290亿美元。我们拟议的研究将提供关于联邦医疗保险对可预防的并发症(即与HAI相关的住院费用减少报销)使用不付款对护理质量和健康结果的影响的关键信息。

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.