The effectiveness of post-acute care

 描述（由申请人提供）：急性期后护理（PAC）是不再需要急性医院服务但病情严重无法出院回家的患者的重要过渡。PAC的使用和成本在过去十年中急剧上升，38%的医疗保险住院导致PAC的使用。2012年，医疗保险在PAC上花费了621亿美元，几乎是十年前的两倍。随着《平价医疗法案》下的支付改革的实施，包括有利于加强护理协调和在多个提供者和环境中捆绑支付的政策，PAC的重要性预计将继续增长。然而，令人惊讶的是，人们对如何有效地使用PAC来改善患者预后知之甚少。医学研究所最近报告说，如果消除PAC使用的差异，每个受益人的医疗保险支出的地理差异可以减少惊人的73%，这表明我们远远没有始终如一地使用PAC。此外，PAC使用对患者结局的影响尚不清楚。本研究的总体目标是检查PAC的使用以及这种使用如何影响成本（总医疗保险成本），患者结局（死亡率，功能状态，出院到社区和重新入院）以及护理价值。与以前的研究不同，我们研究了医院护理和PAC的影响，彼此隔离，共同研究它们的影响。在当前强调护理协调的支付改革下，在整个护理过程中更有效地使用PAC至关重要。此外，虽然大多数以前的研究集中在一种类型的PAC，我们同时在三个最常见的设置：熟练的护理设施（SNFs），住院康复设施（IRFs），和家庭健康机构（HHAs）。我们的具体目标是：1）描述PAC利用率、成本和结果的趋势，将趋势分解为广泛的边际变化（例如，使用任何PAC和每种类型的PAC的人数）和密集余量的变化（例如，以接受一种PAC为条件的护理强度）; 2）联合评估医院护理和PAC对成本、结果和价值的影响; 3）以问责护理组织为例，评估医院和PAC提供者对协调护理激励措施的反应。我们使用强大的准实验方法来识别因果效应。结果将使我们能够确定最有前途的途径，有效地使用PAC，以改善急性住院后的患者结局。他们也将有直接的政策和实践的影响，多设置决策的核心新兴模式的协调照顾。

 DESCRIPTION (provided by applicant): Post-acute care (PAC) serves as an important transition for patients who no longer require acute hospital services but are too sick to be discharged home. The use and costs of PAC have risen dramatically over the past decade, with 38% of Medicare hospitalizations leading to PAC use. In 2012 Medicare spent $62.1 billion on PAC, nearly double what it spent ten years earlier. As payment reform under the Affordable Care Act is implemented, including policies that favor increased coordination of care and bundling payments over multiple providers and settings, the importance of PAC is expected to continue to grow. Yet, surprisingly little is known about how to effectively and efficiently use PAC to improve patient outcomes. The Institute of Medicine recently reported that geographic variation in Medicare spending per beneficiary could be reduced by an astounding 73% if variation in PAC use were eliminated, suggesting that we are far from using PAC consistently. Furthermore, the effect of PAC use on patient outcomes is unclear. The overall goal of this study is to examine the use of PAC and how that use affects costs (total Medicare costs), patient outcomes (mortality, functional status, discharge to the community, and readmissions to the hospital), and value of care. Unlike previous studies that have examined the effects of hospital care and PAC in isolation from one another, we examine their effects jointly. Under current payment reforms that emphasize coordination of care, it is essential to inform more effective PAC use throughout episodes of care. In addition, while most previous studies focus on a single type of PAC, we look simultaneously at the three most common settings: skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and home health agencies (HHAs). Our specific aims are 1) to describe trends in PAC utilization, costs, and outcomes, decomposing the trends into changes on the extensive margin (e.g., the number of people using any PAC and each type of PAC) and changes on the intensive margin (e.g., the intensity of care conditional on receiving a type of PAC); 2) to assess jointly the impact of hospital care and PAC on costs, outcomes, and value; and 3) to assess the response by hospitals and PAC providers to incentives for coordination of care, using Accountable Care Organizations as an example. We use strong quasi-experimental methods to identify causal effects. Results will enable us to identify the most promising avenues for using PAC efficiently and productively to improve patient outcomes after an acute hospitalization. They will also have direct policy and practice implications for the multi-setting decision-making central to emerging models of coordinated care.