Objective:We extend the literature on comorbidity measurement by developing 2 indices, based on the Elixhauser Comorbidity measures, designed to predict 2 frequently reported health outcomes: in-hospital mortality and 30-day readmission in administrative data. The Elixhauser measures are commonly us

Identifying Increased Risk of Readmission and In-hospital Mortality Using Hospital Administrative Data: The AHRQ Elixhauser Comorbidity Index.

BackgroundIn the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs. MethodsUsing Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers. ResultsAdjusted Medica...

https://www.nejm.org/doi/pdf/10.1056/NEJMsa1600142

Early Performance of Accountable Care Organizations in Medicare.

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. Prospero registration number: 42016037725
 .

/pdf/the-effects-of-integrated-care-a-systematic-review-of-uk-and-c1eqylzc99.pdf

The effects of integrated care: a systematic review of UK and international evidence

Background Spending and quality under global budgets remain unknown beyond 2 years. We evaluated spending and quality measures during the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC). Methods We compared spending and quality among enrollees whose physician organizations entered the AQC from 2009 through 2012 with those among persons in control states. We studied spending changes according to year, category of service, site of care, experience managing risk contracts, and price versus utilization. We evaluated process and outcome quality. Results In the 2009 AQC cohort, medical spending on claims grew an average of $62.21 per enrollee per quarter less than it did in the control cohort over the 4-year period (P<0.001). This amount is equivalent to a 6.8% savings when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (P<0.001), 9.1% (P<0.001), an...

/pdf/changes-in-health-care-spending-and-quality-4-years-into-4320x18bnt.pdf

Changes in Health Care Spending and Quality 4 Years into Global Payment

Background Emergency department (ED) care is a focus of cost reduction efforts. Costs for acute care originating in the ED, including outpatient and inpatient encounters (i.e. ED episodes), have not been estimated. Objective We estimate total US costs of ED episodes, potentially avoidable costs, and proportional costs of national health expenditures (NHEs). Methods We conducted a secondary analysis of 2010 data from the Medical Expenditure Panel Survey, National Hospital Ambulatory Medical Care Survey, and the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Outpatient ED encounters were categorized based on the New York University algorithm and admissions by ambulatory care–sensitive condition (ACSC) vs non-ACSC. Potentially avoidable encounters were nonemergent ED visits and ACSC hospital admissions. Using the Medical Expenditure Panel Survey, we determined mean per-visit payments for each visit type. Using the National Hospital Ambulatory Medical Care Survey and Nationwide Inpatient Sample, we estimated aggregate expenditures and proportional costs of NHE by visit category. Results Emergency department episodes of care accounted for $328.1 billion in payments in 2010. This represented 12.5% of NHE; ED admissions were 8.3% and outpatient ED care was 4.2%. Nonemergent outpatient visits were the most common, comprising 30.4% of ED episodes, and non-ACSC admissions were the most costly at $188.3 billion. Potentially avoidable encounters accounted for $64.4 billion, 19.6% of ED episodes, and 2.4% of NHE. Conclusions More than 1 in 10 health care dollars is spent on ED episodes of care. Of this, less than 1 in 5 dollars is potentially avoidable; therefore, efforts to reduce ED visits through improved primary care may have little impact on overall costs.

Costs of ED episodes of care in the United States.

Accountable care organizations (ACOs) have attracted interest from many policy makers and clinical leaders because of their potential to improve the quality of care and reduce costs. Federal ACO programs for Medicare beneficiaries are now up and running, but little information is available about the baseline characteristics of early entrants. In this descriptive study we present data on the structural and market characteristics of these early ACOs and compare ACOs’ patient populations, costs, and quality with those of their non-ACO counterparts at baseline. We found that ACO patients were more likely than non-ACO patients to be older than age eighty and had higher incomes. ACO patients were less likely than non-ACO patients to be black, covered by Medicaid, or disabled. The cost of care for ACO patients was slightly lower than that for non-ACO patients. Slightly fewer than half of the ACOs had a participating hospital. Hospitals that were in ACOs were more likely than non-ACO hospitals to be large, teachi...

Analysis Of Early Accountable Care Organizations Defines Patient, Structural, Cost, And Quality-Of-Care Characteristics

Background: Longitudinal clinical experiences are a common component of undergraduate medical curricula, yet these programs have not been systematically characterized in US medical schools.Objectiv...

https://www.tandfonline.com/doi/pdf/10.1080/10872981.2018.1444900

A review of longitudinal clinical programs in US medical schools.

PURPOSE To quantify the resident learning curve for cataract surgery using operative time as an indicator of surgical competency, to identify the case threshold at which marginal additional educational benefit became equivocal, and to characterize heterogeneity in residents' pathways to surgical competency. SETTING Academic medical center. DESIGN Large-scale retrospective consecutive case series. METHODS All cataract surgery cases performed by resident physicians as primary surgeon at Massachusetts Eye and Ear from July 1, 2010, through June 30, 2015, were reviewed. Data were abstracted from Accreditation Council for Graduate Medical Education case logs and operative time measurements. A linear mixed-methods analysis was conducted to model changes in residents' cataract surgery operative times as a function of sequential case number, with resident identity included as a random effect in the model to normalize between-resident variability. RESULTS A total of 2096 cases were analyzed. A marked progressive decrease in operative time was noted for resident cases 1 to 39 (mean change -0.17 minutes per additional case, 95% CI, -0.21 to -0.12; P < .001). A modest, steady reduction in operative time was subsequently noted for case numbers 40 to 149 (mean change -0.05 minutes per additional case, 95% CI, -0.07 to -0.04; P < .001). No statistically significant improvement was found in operative times beyond the 150th case. CONCLUSIONS Residents derived educational benefit from performing a greater number of cataract procedures than current minimum requirements. However, cases far in excess of this threshold might have diminishing educational return in residency. Educational resources currently used for these cases might be more appropriately devoted to other training priorities.

Quantifying the educational benefit of additional cataract surgery cases in ophthalmology residency.

Context. The use of carbon monoxide detectors may prevent deaths due to unintentional carbon monoxide poisoning. Currently, there is limited data regarding the characteristics of residential carbon monoxide detector use. Objective. To determine the characteristics of residential carbon monoxide detector use. Methods. A survey was administered to a convenience, cross-sectional sample of Emergency Department patients between June and August 2011. Inclusion criteria included patients who were older than 18 years, able to understand written or spoken English or Spanish, and lived in independent residential settings. Survey questions assessed the presence or absence of carbon monoxide and smoke detectors within the participant's home, the frequency of regular battery changes for both devices, location of carbon monoxide detectors within the home, and reasons for not installing carbon monoxide detectors (if applicable). Correlations between racial background, geographical area of residence (urban versus suburban), and income were also assessed. Results. A total of 1030 patients were surveyed. While 97.8% of respondents reported smoke detector use, only 44.4% had home carbon monoxide detectors installed. Only 17.2% had carbon monoxide detectors installed in or near their sleeping area, the correct location for detector placement. Carbon monoxide detector usage was found to be lowest among households earning less than $25,999 per year (27.3% reported having detectors), non-Caucasians (only 42.0% of African-Americans and 24.7% of Hispanics surveyed reported using detectors compared with 57.8% of Caucasians), renters, and urban residents. Reasons given for not having a carbon monoxide detector varied; many answers were consistent with a lack of awareness of the importance of using carbon monoxide detectors. Discussion and conclusions. Residential carbon monoxide detectors were underutilized compared to smoke detectors. Increased public education, especially for minorities and lower income populations, is necessary regarding the use of carbon monoxide detectors for poisoning prevention. Language: en

Daniel L. Liebman

Papers

Analysis Of Early Accountable Care Organizations Defines Patient, Structural, Cost, And Quality-Of-Care Characteristics

A review of longitudinal clinical programs in US medical schools.

Quantifying the educational benefit of additional cataract surgery cases in ophthalmology residency.

A survey of residential carbon monoxide detector utilization among Connecticut Emergency Department patients.

The Case for Transparency in the Ophthalmology Residency Match.