Observation Stays and Readmissions for Older Adults: Implications for Medicare Policies

老年人的观察停留和再入院：对医疗保险政策的影响

• 批准号: 10341230
• 负责人: Amber Kathleen Sabbatini
• 金额: $ 36.55万
• 依托单位: UNIVERSITY OF WASHINGTON
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-05-15 至 2024-02-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10341230
• 关键词: Address; Admission activity; Affect; Attention; Automobile Driving; Caring; Clinical; Complex; Contractor; Data; Decision Making; Elderly; Emergency department visit; Ensure; Environment; Event; Growth; Health; Hospitalization; Hospitals; Incentives; Incidence; Inpatients; Lead; Length of Stay; Longitudinal trends; Measures; Medicare; Medicare claim; Methods; Older Population; Outcome; Outcome Measure; Outpatients; Patient Care; Patient-Focused Outcomes; Patients; Performance; Policies; Quality of Care; Quasi-experiment; Recovery; Research; Risk; Standardization; Subgroup; Variant; Work; acute care; adverse outcome; base; beneficiary; care costs; care delivery; care outcomes; cohort; cost; design; hospital readmission; improved; minority-serving hospitals; mortality; novel; payment; programs; readmission rates; safety net; trend; virtual

SUMMARY Each year, more than 3.4 million Medicare beneficiaries are hospitalized as outpatients under observation. These observation stays have comprised a rapidly increasing proportion of unscheduled hospitalizations among older adults in the US. Controversial Medicare policies, including the Recovery Audit Contractor (RAC) Program and the 2-Midnight Rule, have greatly incentivized hospitals to care for patients via observation instead of an inpatient admission. Additionally, the Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals with higher-than-expected rates of readmissions for certain conditions, may have also had the untoward consequence of incentivizing hospitals to use observation to avoid readmission penalties. Yet, despite their growing importance in hospital care and the complex policy environment driving their use, few studies have examined how observation stays impact patient’s quality of care and outcomes. Recent evidence shows that 30-day readmissions are increasing among patients with observation stays, despite concomitant declines among inpatients. These disparate trends are significant given that federal quality programs, such as the HRRP, have thus far entirely ignored observation stays in hospital-based care delivery. Similarly, hospitals are not held accountable for other outcomes for patients hospitalized under observation, such as mortality. As a result, there has been little incentive for hospitals to ensure high-quality and effective care for patients with observation stays relative to inpatients. In this context, this study aims to fill critical gaps in our understanding of the consequences the growth of observation stays on patient outcomes. Using longitudinal Medicare claims and quasi-experimental methods, we will specifically answer the following questions: 1) What is the contemporary national landscape of readmissions, post-discharge ED use, mortality, and acute care costs for patients with observation stays, and how does this compare to inpatients across hospitals?; 2) How have current Medicare payment reforms, including the Recover Audit Contractor (RAC) program, 2-Midnight Rule and HRRP, impacted the use of observation stays, and more importantly, have they had unintended consequences on patient outcomes?; 3) Finally, how should observation stays be accounted for in national quality programs to fully reflect the care needs of older adults requiring hospital care? This study will be the most comprehensive examination to date of outcomes for Medicare beneficiaries with observation stays, and is specifically designed to inform clinical and policy decision-making around observation care for older adults.

概括 每年，超过 340 万医疗保险受益人在门诊接受观察。 这些观察住院中非计划住院的比例迅速增加 在美国的老年人中。有争议的医疗保险政策，包括恢复审计承包商 (RAC) 该计划和 2 午夜规则极大地激励了医院通过观察来护理患者 而不是住院。此外，医院再入院减少计划 (HRRP) 对某些情况下再入院率高于预期的医院进行处罚，也可能有 激励医院利用观察来避免再次入院处罚的不良后果。 然而，尽管它们在医院护理中的重要性日益增加，并且复杂的政策环境推动了它们的使用， 很少有研究探讨观察时间如何影响患者的护理质量和结果。最近的 有证据表明，尽管住院观察的患者 30 天再入院率正在增加， 住院患者数量也随之下降。考虑到联邦质量，这些不同的趋势很重要 迄今为止，HRRP 等计划完全忽视了医院护理服务中的观察时间。 同样，医院也不对住院观察患者的其他结果负责， 比如死亡率。因此，医院缺乏动力来确保高质量和有效的医疗服务。 观察患者的护理相对于住院患者而言。在此背景下，本研究旨在填补关键空白 在我们对后果的理解中，观察的增长取决于患者的治疗结果。使用 纵向医保理赔和准实验方法，我们具体解答如下 问题： 1) 当代国家的再入院情况、出院后急诊室使用情况、死亡率、 以及观察期间患者的急性护理费用，以及与其他地区的住院患者相比如何 医院？ 2) 当前的医疗保险支付改革，包括恢复审计承包商 (RAC) 进展如何 计划、2-Midnight Rule 和 HRRP 影响了观察停留的使用，更重要的是，它们是否 对患者的治疗结果有意想不到的影响吗？ 3）最后，观察停留时间应该如何计算 在国家质量计划中充分反映需要住院护理的老年人的护理需求？这项研究 将是迄今为止最全面的医疗保险受益人结果观察检查 停留，专门为围绕观察护理的临床和政策决策提供信息 老年人。