マネージドケアのバックラッシュ後のマネージドケア下での心血管アウトカムの発生率の固定効果分析

Fixed effects analysis of the incidence of cardiovascular outcomes under managed care following the managed care backlash.

• Jerome A Dugan

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アブストラクト:

2008年から2011年までの間のCenters for Medicare and Medicaid Services（CMS）の病院比較ファイル、CMS病院コスト報告書、CMSメディケア・アドバンテージ登録ファイル、およびHealth Resources and Services Administrationのエリアリソースファイルのデータを使用して、研究サンプルを構築した。堅牢な標準誤差、病院固定効果、年度固定効果を用いた多変量固定効果回帰を用いて、マネージドケアの普及が心血管系アウトカムに与える影響を推定した。我々の主要な転帰指標は、救急室のある急性の非連邦病院の急性心筋梗塞およびうっ血性心不全で退院した患者の再入院と死亡率であった。主な分析では、マネージドケアの普及率の増加は、急性心筋梗塞とうっ血性心不全の30日再入院と死亡率の低下と関連していることが明らかになった。病院オーナーシップ分析では、専有病院の急性心筋梗塞の結果のみが統計的に有意であった。すべての病院タイプにおいて、うっ血性心不全の傾向は全サンプルと同様であったが、自己所有病院の方が再入院と死亡率の減少が大きかった。マネージドケア活動の増加は、マネージドケアに対する法律や消費者の反発を受けて、病院の再入院と死亡率の減少と関連しており、病院所有タイプによって影響は異なる。これらの知見は、病院でのケアの質の向上を実現する上でのマネージドケアの重要な役割を強調しています。

ABSTRACTS: To examine the impact of increased managed care activity on 30-day readmission and mortality for acute myocardial infarctions and congestive heart failure in U.S. hospitals following the managed care backlash against managed care cost containment practices.The Centers for Medicare and Medicaid Services (CMS) Hospital Compare files, CMS Hospital Cost Report, CMS Medicare Advantage Enrollment files, and Health Resources and Services Administration Area Resource File data for the period 2008 to 2011 were used to construct the study sample. Multivariate fixed effects regression with robust standard errors, hospital fixed effects, and year fixed effects were used to estimate the impact of managed care penetration on adverse cardiovascular outcomes. Our primary outcome measures were readmission and mortality for patients discharged with acute myocardial infarction and congestive heart failure for acute, non-federal hospitals with emergency rooms. To examine effects of hospital ownership status, not-for-profit hospitals were compared to proprietary hospitals.The main analysis revealed that an increase in managed care penetration was associated with a decline in both 30-day readmission and mortality for acute myocardial infarction and congestive heart failure. In the hospital ownership analysis, only the acute myocardial infarction results for proprietary hospitals was statistically significant. All hospital types reported similar congestive heart failure trends as the full sample; however, proprietary hospitals reported greater declines in readmission and mortality.Increased managed care activity is associated with reductions in hospital readmission and mortality following the legislative and consumer backlash against managed care, with differential impacts across hospital ownership type. These finding highlights the important role of managed care in creating quality improvements in the delivery of care in the hospital setting.