The effects of bundled payment on acute cardiovascular outcomes among older adults

项目总结 冠状动脉疾病每年导致超过36万人死亡，主要是老年人，损失超过100美元 数十亿美元的医疗支出。尽管结果有所改善，但治疗仍然受到不必要的困扰 护理的多样性，加上对高价值护理的利用不足。为了解决这些问题，CMS引入了 几项捆绑支付改革的重点是心脏手术，包括经皮冠状动脉介入治疗和冠状动脉搭桥术。最新的 计划-高级护理改善捆绑支付(BPCI-A)-是一项自愿计划，旨在创建 激励医院在出院后90天内改善患者结果并减少支出 这一集。尽管承诺捆绑付款，但它对常见心脏手术结果的影响是 不是很清楚。改善护理协调和质量的激励措施可能会鼓励医院减少 围术期并发症和严格管理急性后护理转诊。同时，激励措施 减少开支可能会鼓励医院避免病情较严重的患者。在这方面，我们建议 以下目标：目标1.评估医院和患者选择与冠状动脉搭桥术和冠状动脉旁路移植术相关的作用 BPCI-A。我们将把医院对BPCI-A的参与与Medicare数据和CATPCIA数据联系起来， 胸外科医生学会成人心脏外科注册。我们将比较医院和病人的严重程度 仅含索赔的概况(BPCI-A中的现状)和附有登记处数据的索赔(GOLD 标准)。然后，我们将测试1)基于索赔的严重程度低于基于登记表的医院 严重程度不太可能参与BPCI-A；2)基于索赔的严重程度较低的患者变得较少 很可能在BPCI-A之后在参与医院接受治疗。目的2.评价BPCI-A对大鼠心脏功能的影响 围手术期和出院后的结果。使用数以千计的联邦医疗保险索赔和关联数据 参与登记的医院，我们将估计计量经济学模型，以测试BPCI-A是否 与围手术期并发症和出院后结果的改善有关。目标3.评估 BPCI-A的变化和新冠肺炎的交付系统中断如何影响捆绑的未来设计 付款。我们将利用BPCI-A设计的变化来检查是否包括相关的支出 随着心脏康复的发作，导致心脏康复程度降低。我们还会比较医院 使用基于索赔和基于登记的措施以及对患者严重程度变化进行测试的质量表现 住院患者和门诊患者接受经皮冠状动脉介入治疗的资料。最后，我们将检查目标的准确性 新冠肺炎之前和之后的价格。这项提议意义重大，因为它将是第一个理解 使用高质量注册数据，BPCI-A对心脏手术的选择和结果的影响。这个 Proposal在使用新的数据链接和统计方法以了解这一影响方面具有创新性 影响数百万患有冠状动脉疾病的老年人的关键政策问题。

PROJECT SUMMARY Coronary artery disease causes over 360,000 annual deaths, primarily among older adults, and over $100 billion in medical expenditures. Despite improvements in outcomes, treatment remains beset by unwarranted variation in care coupled with underuse of high-value care. To address these problems, CMS has introduced several bundled payment reforms focused on cardiac procedures, including PCI and CABG. The most recent program – Bundled Payment for Care Improvement Advanced (BPCI-A) – is a voluntary program that creates incentives for hospitals to improve patient outcomes and reduce spending across a 90-day post-discharge episode. Despite the promise of bundled payment, its effects on outcomes for common cardiac procedures are not well understood. Incentives to improve care coordination and quality may encourage hospitals to reduce periprocedural complications and tightly manage post-acute care referrals. At the same time, incentives to reduce spending may encourage hospitals to avoid higher severity patients. In this context, we propose the following aims: Aim 1. Evaluate the role of hospital and patient selection related to PCI and CABG episodes in BPCI-A. We will link hospital participation in BPCI-A with Medicare data and data from the CathPCI and Society of Thoracic Surgeons Adult Cardiac Surgery registries. We will compare hospital and patient severity profiles with claims alone (the status quo in BPCI-A) and claims supplemented with registry data (the gold standard). We will then test whether hospitals with 1) lower claims-based severity compared to registry-based severity were less likely to participate in BPCI-A; and 2) patients with lower claims-based severity became less likely to be treated at participating hospitals after BPCI-A. Aim 2. Evaluate the effects of BPCI-A on periprocedural and post-discharge outcomes. Using Medicare claims and linked data from thousands of hospitals participating in the registries, we will estimate econometric models to test whether BPCI-A was associated with improvements in periprocedural complications and post-discharge outcomes. Aim 3. Evaluate how changes in BPCI-A and delivery system disruptions from COVID-19 inform the future design of bundled payment. We will exploit a change in the design of BPCI-A to examine whether including spending associated with cardiac rehabilitation in the episode led to lower cardiac rehabilitation. We will also compare hospital quality performance using claims-based and registry-based measures and test for shifts in patient severity profiles for patients receiving inpatient and outpatient PCI. Finally, we will examine the accuracy of target prices before and after COVID-19. This proposal is significant because it will be the first to understand the effects of BPCI-A on selection and outcomes for cardiac procedures using high quality registry data. The proposal is innovative in its use of novel data linkages and statistical methods to understand the impact of this critical policy question affecting millions of older adults with coronary artery disease.