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

摘要 每年有超过340万的医疗保险受益人作为门诊患者住院接受观察。 这些观察停留时间构成了非计划住院的迅速增加的比例。 在美国的老年人中。备受争议的医疗保险政策，包括恢复审计承包商(RAC) 计划和午夜2规则，极大地激励了医院通过观察来照顾病人 而不是住院治疗。此外，医院再入院减少计划(HRRP)， 惩罚因某些情况再次入院率高于预期的医院，可能也 激励医院使用观察来避免重新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与日俱增，而且推动它们使用的复杂政策环境， 很少有研究研究观察停留时间如何影响患者的护理质量和结果。近期 有证据表明，在有观察停留的患者中，30天的再入院时间正在增加，尽管 在住院患者中，伴随而来的是下降。考虑到联邦政府的质量，这些不同的趋势意义重大 到目前为止，HRRP等项目完全忽视了以医院为基础的护理服务中的观察停留时间。 同样，医院对在观察中住院的患者的其他结果不承担责任， 比如死亡率。因此，医院几乎没有动力来确保高质量和有效的 护理观察停留患者相对于住院患者。在此背景下，本研究旨在填补关键空白 在我们对结果的理解中，观察的增长取决于患者的结果。vbl.使用 纵向医疗保险申领和准实验方法，我们将具体回答以下几个问题 问题：1)重新入院、出院后ED的使用、死亡率、 和观察停留的患者的急性护理费用，这与住院患者相比如何 医院？；2)当前的医疗保险支付改革，包括恢复审计承包商(RAC) 计划，2-午夜规则和HRRP，影响了观察停留的使用，更重要的是，他们 是否对患者的结局产生了意想不到的后果？3)最后，观察停留时间应如何计算 为了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？本研究 将是迄今为止对医疗保险受益人结果进行的最全面的检查，并进行观察 停留，并被专门设计为围绕观察护理的临床和政策决策 上了年纪的人。

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.