住院病人预先护理规划的质量改进计划。

IF 9.5 Q1 HEALTH CARE SCIENCES & SERVICES
Olivia A Sacks, Megan Murphy, James O'Malley, Nancy Birkmeyer, Amber E Barnato
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引用次数: 0

摘要

重要性:美国医疗保险与医疗补助服务中心(CMS)于 2016 年实施了预先护理计划(ACP)计费代码,以鼓励从业人员开展并记录 ACP 对话,并在 2018 年将 ACP 作为一项质量指标纳入 CMS 护理改进捆绑支付计划。在住院环境中使用该计费代码的情况尚未进行研究:目的:确定旨在提高住院患者 ACP 的质量改进干预措施是否能有效提高 ACP 账单率或改变医院治疗计划或患者预后:这项全国范围内的队列研究和差异分析比较了 65 岁及以上住院并接受三组不同人员护理的联邦医疗保险付费服务受益人在 ACP 账单、治疗和预后方面的变化:接受 ACP 质量改进干预的全国性急症护理人员组织聘用的从业人员、同一医院未接受干预的从业人员以及来自其他医院的对照组从业人员。利用主受益人摘要档案中的数据,将 2015 年至 2019 年期间非手术治疗的急症护理住院情况与入院前 1 年至入院后 1 年的医疗保险注册、理赔和生命体征数据联系起来。评估了每组的 ACP 账单率与 6 种住院治疗和 4 种结果的关联性。数据分析时间为 2022 年 1 月至 2024 年 12 月:主要结果和测量指标:ACP会话账单、接受重症监护和生命支持(重症监护室入院、胃造瘘管置入、机械通气、气管切开术)、治疗限制(新启动的拒绝复苏指令)和结果(出院至临终关怀、住院患者死亡、入院后30天死亡和入院后1年死亡):研究样本包括 109 家干预医院、1691 家对照医院、近 1200 万名 65 岁及以上的医疗保险付费服务受益人,以及 738 309 名与 2016 年至 2018 年入院相关的从业人员。干预措施的 ACP 账单率增加较多(干预前为 1.3%,干预后为 14.0%;P 结论和相关性:这项全国范围的队列研究表明,虽然 ACP 质量倡议提高了 ACP 账单率,但临床结果的变化与假设不一致。还需要进一步研究,以解决未观察到的医疗质量衡量标准造成的混淆问题。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
A Quality Improvement Initiative for Inpatient Advance Care Planning.

Importance: The Centers for Medicare & Medicaid Services (CMS) implemented advance care planning (ACP) billing codes in 2016 to encourage practitioners to conduct and document ACP conversations, and included ACP as a quality metric in the CMS Bundled Payments for Care Improvement Initiative in 2018. Use of this billing code in the inpatient setting has not been studied.

Objective: To determine whether a quality improvement intervention to increase inpatient ACP is effective in increasing ACP billing rates or changing hospital treatment plans or patient outcomes.

Design, settings, and participants: This nationwide cohort study and difference-in-differences analyses compared changes in ACP billing, treatment, and outcomes in Medicare fee-for-service beneficiaries aged 65 years and older who were hospitalized and cared for by 3 different groups: practitioners employed by a national acute care staffing organization who underwent an ACP quality improvement intervention, nonintervention practitioners at the same hospital, and control group practitioners from other hospitals. Using data from the Master Beneficiary Summary File, acute care hospital stays for nonsurgical conditions were linked to Medicare enrollment, claims, and vital status data from 1-year preadmission to 1-year postadmission from 2015 to 2019. The ACP billing rates for each group were assessed for associations with 6 inpatient treatments and 4 outcomes. Data analyses were performed from January 2022 to December 2024.

Main outcomes and measures: Billed ACP conversations, receipt of intensive care and life support (intensive care unit admission, gastrostomy tube placement, mechanical ventilation, tracheostomy), treatment limitations (newly initiated do-not-resuscitate orders) and outcomes (discharge to hospice, inpatient death, 30-day postadmission death, and 1-year postadmission death).

Results: The total study sample included 109 intervention hospitals, 1691 control hospitals, nearly 12 million Medicare fee-for-service beneficiaries aged 65 years and older, and 738 309 practitioners associated with admissions from 2016 to 2018. ACP billing rates increased more for the intervention (1.3% in preintervention to 14.0% in postintervention; P < .001) than for the nonintervention (same hospitals) and control groups (odds ratio [OR], 2.6; 95% CI, 1.7-4.1 intervention vs control). Increased ACP billing rates were significantly associated with decreased rates of inpatient death in the intervention group (OR, 0.95; 95% CI, 0.90-1.00) compared to the nonintervention (OR, 1.10; 95% CI, 1.04-1.17) and control groups (reference). All other associations were nonsignificant.

Conclusions and relevance: This nationwide cohort study suggests that while the ACP quality initiative increased ACP billing, changes in clinical outcomes were inconsistent with the hypotheses. Further study is needed to address questions regarding confounding by unobserved measures of care quality.

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来源期刊
CiteScore
4.00
自引率
7.80%
发文量
0
期刊介绍: JAMA Health Forum is an international, peer-reviewed, online, open access journal that addresses health policy and strategies affecting medicine, health, and health care. The journal publishes original research, evidence-based reports, and opinion about national and global health policy. It covers innovative approaches to health care delivery and health care economics, access, quality, safety, equity, and reform. In addition to publishing articles, JAMA Health Forum also features commentary from health policy leaders on the JAMA Forum. It covers news briefs on major reports released by government agencies, foundations, health policy think tanks, and other policy-focused organizations. JAMA Health Forum is a member of the JAMA Network, which is a consortium of peer-reviewed, general medical and specialty publications. The journal presents curated health policy content from across the JAMA Network, including journals such as JAMA and JAMA Internal Medicine.
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