The Distribution of Additional Residency Slots to Rural and Underserved Areas.

This study analyzes data from the Centers for Medicare & Medicaid Services to identify whether new residency training slots went to rural and underserved areas with the greatest need.

Telehealth medication management and health care spending in a Medicare Accountable Care Organization.

BACKGROUND: Value-based care is an opportunity for medication optimization services to improve medication management and reduce health care spending. The reach of these services may be extended through telehealth. However, as health care systems and payers grapple with the long-term financing of telehealth, real-world assessments are needed to evaluate the potential economic impact of pharmacy-driven telehealth services. OBJECTIVE: To evaluate the impact of a scalable pharmacist-driven telehealth intervention to improve medication management on health care spending for clinically complex patients who were enrolled in a Medicare Next Generation Accountable Care Organization. METHODS: Data for this pretest-posttest nonequivalent group design study came from Medicare claims from 2015 to 2020 and linked pharmacist care activity data derived from the electronic medical record. Patients in the intervention group were identified as those who received the telehealth medication management service. Patients in the control group were offered the service and refused or could not be contacted. The primary outcome was total medical spending over a 6-month period, and impact was assessed using a covariate-adjusted difference-in-difference model. RESULTS: There were 581 patients who received the intervention and 1,765 who served as controls. The telehealth intervention reduced total medical spending by $2,331.85 per patient over the first 6 months of the service ($388.50 per month; P = 0.0261). Across a range of estimates for the cost of service delivery, we find a return on investment of 3.6:1 to 5.2:1. CONCLUSIONS: The $388.50 monthly savings found in this study represent a substantial reduction in health care spending and emphasize the opportunity for telehealth delivery of medication management services to improve value as a part of alternative payment models. DISCLOSURES: This study was funded by the UNC Health Care Department of Pharmacy. Dr Urick has received personal fees from Pharmacy Quality Solutions and Cardinal Health. Drs Peters, Vest, Colmenares, Foushee, and DeFalco are employees of UNC Health Care Department of Pharmacy. Mr Easter received a Co-PI grant from NACDS Foundation to implement Community-based Value Care Initiative (CVCI) in a community pharmacy setting. He also received a grant to Eshelman School of Pharmacy. He has an individual consulting agreement with digital health company Truentity Health to provide go to market strategy for medication management services. He also has stock options from Truentity Health as a component of the consulting agreement. Dr Foushee has a leadership or fiduciary role at Member-At-Large and the Ambulatory Care Academy of the North Carolina Association of Pharmacists. At the time this work was conducted, Dr Urick, Dr Pathak, and Dr Blanchard were all employees of the UNC Eshelman School of Pharmacy.

Comprehensive medication management by pharmacists via telehealth in rural primary care: is it feasible and effective?

INTRODUCTION: Patients with uncontrolled diabetes living in rural communities experience many challenges, including lack of access to needed medication management services. Telepharmacy has been identified as a promising approach for addressing this gap. This presentation describes early insights into the implementation of a Comprehensive Medication Management (CMM) service in seven rural primary care clinics in North Carolina and Arkansas (USA). The CMM service involved two pharmacists meeting remotely with patients in their homes to identify and resolve Medication Therapy Problems (MTPs). STUDY DESIGN: This exploratory mixed methods study uses a pre-post design. Data sources include surveys, qualitative interviews, administrative data, and medical records (eg MTPs, hemoglobin A1Cs) collected as part of the first 3 months of a 1-year implementation period. METHODS: Lessons learned were identified through qualitative interviews with six clinic liaisons, review of pharmacists' observations, and open-ended survey questions with clinic staff and providers. Early service effectiveness was informed by MTP resolution rates and changes in patients' A1C levels. RESULTS: Key insights centered on the perceived benefits of the service for patients and clinics, the importance of patient engagement, access to implementation strategies (eg workflows and technical assistance calls), and the need to adapt the CMM service and implementation strategies to local context. The MTP resolution rate averaged 88% across pharmacists. There was a significant decrease in A1Cs in participating patients as a result of the service. CONCLUSION: Although preliminary, these results support the value of a pharmacist-led medication optimization service through remote delivery for complex patients with uncontrolled diabetes.

Impact of Expanding Access to Continuous Glucose Monitoring Systems Among Insulin Users with Type 1 or Type 2 Diabetes.

Background: Despite increased use of continuous glucose monitoring (CGM) systems, studies to quantify patterns of CGM use are limited. In December 2018, a policy change by a commercial insurer expanded coverage of CGM through the pharmacy benefit, creating an opportunity to evaluate the impact of this change on CGM utilization. Research Design and Methods: Pharmacy and medical claims from 2016 to 2020 were used to estimate the prevalence of CGM use among insulin users with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) before and after the policy change. Change in CGM use was assessed using an interrupted time series design. Results: At the beginning of the study period, 18.8% of T1DM patients and 1.2% of T2DM patients used CGM. Use rose to 30.5% and 6.6% in the quarter before the policy change. The policy resulted in an immediate 9.5% (P < 0.0001) and 2.8% (P < 0.0001) change in use and increased the rate of quarterly change by 0.5% (P = 0.002) and 0.8% (P < 0.0001). At the end of the study period, 58.2% and 14.9% of T1DM and T2DM patients used CGM. Conclusion: CGM use significantly increased after addition to the pharmacy benefit. Rate of change in CGM use was lower in T1DM compared to the T2DM population, but overall use remained higher among patients with T1DM. Increased CGM use in the population studied aligns with those whose clinical guidelines suggest would most likely benefit. Additional work is needed to evaluate the impact of this benefit change on health care spending and outcomes.

Bolstering the rural physician workforce in underserved communities: Are Rural Residency Planning and Development Programs finding the sweet spot?

PURPOSE: The purpose of this study is to describe the characteristics of Rural Residency Planning and Development (RRPD) Programs, compare the characteristics of counties with and without RRPD programs, and identify rural places where future RRPD programs could be developed. METHODS: The study sample comprised 67 rural sites training residents in 40 counties in 24 US states. Descriptive statistics were used to describe RRPD programs and logistic regression to predict the probability of a county being an RRPD site as a function of population, primary care physicians (PCP) per 10,000 population, and the social vulnerability index (SVI) compared to a control sample of nonmetro counties without RRPD sites. FINDINGS: Most RRPD grantees (78%) were family medicine programs affiliated with medical schools (97%). RRPD counties were more populous (P<.01), had a higher population density (P<.05), and a higher percent of the non-White or Hispanic population (P = .05) compared to non-RRPD counties. Both higher population (P<.001) and PCP ratio (P = .046) were strong predictors, while SVI (P = .07) was a weak predictor of being an RRPD county. CONCLUSIONS: RRPD sites appear to represent a "sweet spot" of rural counties that have the population and physician supply to support a training program but also are relatively more socially vulnerable with high-need populations. Additional counties fitting this "sweet spot" could be targeted for funding to address health disparities and health workforce maldistribution.

Relative contribution of pharmacists and primary care providers to shared quality measures.

Background: Alternative payment models are common for both primary care providers and pharmacies. These models rely on quality measures to determine reimbursement, and pharmacists and primary care providers can contribute to performance on a similar set of medication-related measures. Therefore, payers need to decide which provider to incentivize for which measures when both are included in alternative payment models. Objectives: To explore the relative contribution of pharmacies and primary care group practices to a range of quality measures. Methods: This retrospective cross-sectional study used Medicare Part A, B, and D claims for a 20% random sample of Medicare beneficiaries for 2014-2016. Eight quality measures were selected from the Merit-based Incentive Payment System and Medicare Part D Stars Ratings. Measures included medication adherence measures, appropriate prescribing measures such as high-risk medication use in the elderly, statin use in persons with diabetes (SUPD), and others. The residual intraclass correlation coefficient (RICC) was used to estimate the contribution of pharmacists and primary care providers to measure variation. To estimate the relative contribution across provider types, the pharmacy RICC was divided by the group practice RICC to yield a RICC ratio. Results: Due to varying measure eligibility requirements, the number of patients per measure ranged from 179,430 to 2,226,129. Across all measures, the RICC values were low, ranging from 0.013 for SUPD to 0.145 for adult sinusitis. Adherence measures had the highest RICC ratios (1.15-1.44), and the annual influenza vaccination measure had the lowest (0.56). Discussion and conclusions: The relative contributions of pharmacists and primary care providers vary across quality measures. As payers design payment models with measures to which pharmacists and primary care providers can contribute, the RICC ratio may be useful in aligning incentives to the providers with the greatest relative contributions. Additional research is needed to validate this method and extend it to additional sets of providers.

Pharmacists as accessible health care providers: quantifying the opportunity.

BACKGROUND: Community pharmacists are well positioned to improve patient access to care, which may assist value-based care programs in reaching patients. While pharmacy accessibility is broadly acknowledged, much of the research supporting accessibility claims is poor quality. OBJECTIVE: To quantify the accessibility of pharmacists in comparison with physicians or qualified health care professionals (QHP) in a commercially insured population. METHODS: IBM MarketScan claims data from 2018 were used for this cross-sectional study. Beneficiaries included in the primary analysis were aged 18-64 years, enrolled with pharmacy benefits in 2018 for 12 months, and had at least 1 valid prescription drug claim or evaluation and management (E&M) code in 2018. Unique pharmacy visits were defined using a 6-day fill window for prescription fill dates, while visits to physicians or other QHP were defined as unique service dates tied to an E&M code. We assessed differences in visit frequency for the full sample, those with multiple chronic conditions (MCC), and "superutilizers" (top 5% based on total cost of care). Our statistical approach included descriptive statistics and the Wilcoxon sign rank test. RESULTS: After applying the inclusion criteria, 11,720,958 beneficiaries were included in the full sample. The MCC cohort contained 13.8% of the total sample (mean [SD] age: 50.8 [10.8]; 908,880 [56.1%] female). Finally, the superutilizers were 57.3% female with an average age of 48.4 years and comprised 5.3% of the total sample. The median number of pharmacy and physician or QHP visits for the full sample were 5 and 3 (P < 0.0001), yielding a pharmacy to physician or QHP visit ratio of 1.7:1. The MCC cohort had a median of 13 pharmacy visits and 7 physician or QHP visits (ratio 1.9:1; P < 0.0001), and the superutilizers had a median of 14 pharmacy visits and 9 physician or QHP visits (ratio 1.6:1; P < 0.0001). CONCLUSIONS: This study found that patients visit their community pharmacies almost twice as often as they visit their physicians or other QHP. Study findings emphasize the accessibility of community pharmacists and highlight the role of community pharmacists in improving patient engagement in all care programs, including value-based care programs. DISCLOSURES: The database infrastructure used for this project was funded by the Department of Epidemiology, University of North Carolina (UNC) Gillings School of Global Public Health; the Cecil G. Sheps Center for Health Services Research, UNC; the CER Strategic Initiative of UNC's Clinical Translational Science Award (UL1TR001111); and the UNC School of Medicine. All authors are employed by the UNC School of Pharmacy. Urick declares consulting fees from Cardinal Health. The other authors have no conflicts of interest to disclose. Portions of this work were previously presented at the AMCP 2021 Virtual, April 12-16, 2021.

Performance-based pharmacy payment models: key components and critical implementation considerations for successful uptake and integration.

BACKGROUND: In the United States, the shift towards value-based health care seeks to improve patient outcomes while reducing health care spending. Although the federal government has led the implementation of performance-based models for physicians and health care systems, commercial entities have largely been responsible for the development of similar models within pharmacy. For the purposes of this study, performance-based pharmacy payment models (PBPPMs) were defined as prescription drug payment models that determine reimbursement or fees for community pharmacies based in part on measured performance. These PBPPMs incentivize pharmacies to improve patient care by linking reimbursement to performance measures. However, the design and implementation of PBPPMs lack transparency and have not been described in the literature. OBJECTIVES: To (1) describe the structure of PBPPMs in the United States and (2) identify contextual and motivational influences that need to be considered for successful uptake and integration of these models. METHODS: A search of peer-reviewed and grey literature was undertaken. In addition, semi-structured stakeholder interviews were conducted with a convenience sample of 17 individuals who were community pharmacists, payers, quality measure developers and vendors, academics, and pharmacy advocacy organization leaders. Data were analyzed to understand the current structure of PBPPMs and opportunities for improvement, as well as implementation considerations that included facilitators, barriers, and key insights. RESULTS: This study identified 4 major components of US PBPPMs: attribution, performance and quality measures, incentive structures, and patient care services. A number of barriers (eg, lack of alignment) and recommendations to improve the current structure of PBPPMs (eg, the need for adequate incentives to facilitate change) were highlighted. Notable implementation considerations centered around (1) establishing common ground among stakeholders to avoid misalignment and encourage engagement; (2) the importance of a quality-driven, innovative, and flexible organizational culture with access to data infrastructure, adjusted workflows, and relevant trainings; (3) supporting the cultural transition to value-based health care; and (4) application of financial incentives at the pharmacy or pharmacist level. CONCLUSIONS: To better develop and implement PBPPMs, it is first critical to understand the key components that define these models and the needed changes to their structure. In addition, identifying the contextual and motivational factors that influence their successful integration can improve future uptake. This study illustrates the landscape of PBPPMs in the United States, as well as makes recommendations for improvement in their design. To improve future development and implementation of these models, the following recommendations are highlighted: (1) increase transparency and alignment of measures with the incentive structure; (2) embrace innovative business models; (3) carefully plan and use roadmaps that outline successful uptake and implementation; and (4) foster culture of quality at all levels of health care. DISCLOSURES: This study was sponsored by Pharm-Alliance, an alliance between the pharmacy schools of the University of North Carolina at Chapel Hill, Monash University, and University College London. Urick reports consulting fees from Pharmacy Quality Solutions and Cardinal Health, unrelated to this work. The other authors have nothing to disclose. This study was a podium presentation under the title "What Makes Performance-Based Pharmacy Payment Models Work?" at AMCP Nexus Virtual, October 2020.

Screening and Referral Care Delivery Services and Unmet Health-Related Social Needs: A Systematic Review.

INTRODUCTION: Unmet health-related social needs contribute to high patient morbidity and poor population health. A potential solution to improve population health includes the adoption of care delivery models that alleviate unmet needs through screening, referral, and tracking of patients in health care settings, yet the overall impact of such models has remained unexplored. This review addresses an existing gap in the literature regarding the effectiveness of these models and assesses their overall impact on outcomes related to experience of care, population health, and costs. METHODS: In March 2020, we searched for peer-reviewed articles published in PubMed over the past 10 years. Studies were included if they 1) used a screening tool for identifying unmet health-related social needs in a health care setting, 2) referred patients with positive screens to appropriate resources for addressing identified unmet health-related social needs, and 3) reported any outcomes related to patient experience of care, population health, or cost. RESULTS: Of 1,821 articles identified, 35 met the inclusion criteria. All but 1 study demonstrated a tendency toward high risk of bias. Improved outcomes related to experience of care (eg, change in social needs, patient satisfaction, n = 34), population health (eg, diet quality, blood cholesterol levels, n = 7), and cost (eg, program costs, cost-effectiveness, n = 3) were reported. In some studies (n = 5), improved outcomes were found among participants who received direct referrals or additional assistance with indirect referrals compared with those who received indirect referrals only. CONCLUSION: Effective collaborations between health care organizations and community-based organizations are essential to facilitate necessary patient connection to resources for addressing their unmet needs. Although evidence indicated a positive influence of screening and referral programs on outcomes related to experience of care and population health, no definitive conclusions can be made on overall impact because of the potentially high risk of bias in the included studies.

A Systematic Review of the Effect of Telepharmacy Services in the Community Pharmacy Setting on Care Quality and Patient Safety.

While community pharmacy-based telepharmacy services can expand medication access for underserved communities, the safety and quality of these services is uncertain. A systematic review was conducted in August 2020 exploring the effect of community pharmacy-based telepharmacy services on patient safety and care quality. Database searches identified 866 studies, of which six met the inclusion and the risk of bias measurement criteria. Medication dispensing errors, adherence, and patient satisfaction were the most frequently evaluated outcomes. Literature suggests no overall difference in medication safety and adherence, conflicting evidence on patient satisfaction, and insufficient evidence on inappropriate medication use in community pharmacy-based telepharmacies compared with traditional pharmacies. Due to the potential for high risk of bias, no definitive conclusions could be made about telepharmacy outcomes. Research with stronger study designs and more rigorous evaluation methodologies is needed to create conclusive evidence on the effectiveness of community pharmacy-based telepharmacy services.

Design and effect of performance-based pharmacy payment models.

BACKGROUND: Community pharmacy participation in performance-based payment models has increased in recent years. Despite this, there has been neither much research done to evaluate the effect of these models on health care quality and spending nor is there extensive literature on the design of these models. OBJECTIVES: To (a) describe the types of measures used in performance-based pharmacy payment models (PBPPMs); (b) describe the financial impact of PBPPMs on pharmacies; (3) explore pharmacy owners' perceptions of PBPPMs; and (4) describe any practice changes made in response to PBPPMs. METHODS: This is a cross-sectional study that surveyed independent community pharmacy owners between November 2019 and January 2020. The survey included 45 items split into 5 sections that covered respondent characteristics and the 4 domain objectives. Descriptive statistics were used for quantitative responses, and free-text responses were assessed for themes. RESULTS: Of the 68 individuals who responded to the survey, 42 were community pharmacy owners who met the study eligibility criteria, and 30 responded to most survey items. Owners expressed frustration at the design of PBPPMs, with 90% stating that they did not feel that the actions necessary to meet or exceed performance standards were within their control, and 90% also reported a loss of revenue because of these models. In addition, large numbers of respondents felt that they did not have enough information on how performance measures were computed (76.7%) or how cut-points were determined (86.7%). Despite negative feelings, most owners reported implementing changes in service offerings as a result of these models. CONCLUSIONS: PBPPMs appear to be commonplace and put substantial financial burden on community pharmacies. Study results suggest that greater education by payers could improve pharmacist engagement, as could involvement of pharmacies in the design and maintenance of PBPPMs. DISCLOSURES: This work was supported by a grant from the American Association of Colleges of Pharmacy, which was not involved in the collection, analysis, and interpretation of data; writing of the report; or the decision to submit this article for publication. Urick reports consulting fees from Pharmacy Quality Solutions. The other authors declare no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Telepharmacy and Quality of Medication Use in Rural Areas, 2013-2019.

INTRODUCTION: Pharmacy closures in rural areas is an increasingly common problem. Closures disrupt medication access and decrease adherence to prescription medications. Telepharmacy is a potential solution to this problem; however, research on the relationship between telepharmacy and the quality of medication use is scarce. Our study sought to address this gap by comparing the quality of telepharmacies serving rural areas and traditional pharmacies that support them. METHODS: We obtained dispensing data for the first 18 months of operation from 3 telepharmacies and 3 traditional pharmacies located in the upper Midwest. We evaluated adherence for noninsulin diabetes medications, renin-angiotensin system antagonists, and statins, as well as inappropriate use of high-risk medications in older adults and statin use in persons with diabetes. All metrics were calculated using Medicare Part D specifications. We estimated the differences between telepharmacies serving rural areas and traditional pharmacies using generalized linear regression. We adjusted our models for potential sociodemographic and clinical confounders. RESULTS: A total of 2,832 patients contributed 4,402 observations to the quality measures. After covariate adjustment, we observed no significant differences between telepharmacies and traditional pharmacies for noninsulin diabetes medications, renin-angiotensin system antagonists, statins, and high-risk medications. However, statin use in persons with diabetes was higher in telepharmacies than traditional pharmacies. CONCLUSION: We found that the quality of medication use at telepharmacies that serve rural areas was no worse than at traditional pharmacies. For communities considering the adoption of telepharmacy, results indicate that telepharmacies provide a suitable solution for expanding medication access and that using telepharmacy would not negatively affect the quality of medication use.

Is Post-discharge Rehabilitation Timing Associated with 90-Day Readmission in Primary Total Joint Arthroplasty?

BACKGROUND: Physical therapy (PT) is an accepted standard of care after total joint arthroplasty (TJA) and essential to maximizing joint functionality and minimizing complications that lead to readmission. However, evidence-based guidelines about appropriate post-discharge rehabilitative care are not well-defined in the orthopedic literature. PURPOSES: We sought to determine the average timing for receiving PT rehabilitation and to evaluate the association between PT rehabilitation timing and unplanned readmission within 90 days of a TJA patient being discharged home from acute care. METHODS: This retrospective study examined 11,545 joint procedures using claims data for the years 2008 to 2013. Outcomes were assessed using a population-averaged approach to regression models. RESULTS: The average time for initiating PT was 4 days for knee arthroplasty and 6 days for hip arthroplasty in patients discharged home from acute care. Most patients (89%) began PT consultation or supervised exercises during the first week after discharge. The type of joint surgery considerably modified the effect of rehabilitation timing on the likelihood of readmission. Later initiation of rehabilitation was associated with a higher probability of 90-day readmission in both knee and hip arthroplasty, with the effect of rehabilitation timing being more pronounced in hip rather than knee arthroplasty 2 weeks post-discharge from acute care. CONCLUSIONS: Timing for initiating PT may be an important modifiable factor that can affect readmission in patients discharged home from acute care after TJA. Further exploration of the role of PT timing along with other factors such as dosage and frequency among such patients is needed.

Does care consultation affect use of VHA versus non-VHA care?

OBJECTIVES: The Partners in Dementia Care (PDC) intervention has shown improved psychosocial outcomes while reducing overall inpatient and emergency department (ED) utilization among veterans with cognitive impairment and behavioral symptoms. However, veterans who use the Veterans Health Administration (VHA) also seek care from non-VHA sources, potentially reducing the effectiveness of care coordination. We evaluated whether PDC affected VHA and non-VHA inpatient and ED use by veterans with dementia. STUDY DESIGN: PDC is a telephone-based care coordination and support service program implemented in 2 VHA intervention sites that were compared with 3 VHA control sites. Veterans with a dementia diagnosis and their caregivers participated. METHODS: Data came from administrative records and structured interviews with caregivers. We modeled the likelihood of site of care across 3 periods: preintervention (baseline), baseline to 6 months, and 6 months to 12 months. RESULTS: Compared with veterans at control sites, veterans at intervention sites who lived closer to VHA medical centers showed an increase over time (P ≤.01) in the likelihood of seeking VHA inpatient care as opposed to non-VHA care, whereas the likelihood of seeking non-VHA relative to VHA inpatient care increased for veterans living further away. ED visits did not show a comparable intervention effect. CONCLUSIONS: PDC intervention affected the choice of VHA versus non-VHA inpatient care, with its impact differing by distance from VHA medical centers. Site of ED care was not affected. Accountable care organizations share some of the VHA's vulnerabilities to out-of-system use; thus, the implications of our findings extend beyond the VHA system.

Isolated Congenital Tracheobiliary Fistula.

BACKGROUND: Congenital tracheobiliary fistula is a rare developmental anomaly with a persistent communication between the biliary system and the trachea. CHARACTERISTICS: A 7-day-old baby with severe respiratory distress and aspiration pneumonia. OUTCOME: Tracheobilliary fistula identified on bronchoscopy. Open surgical excision of fistula was followed by improvement. MESSAGE: This condition should be considered in the differential diagnosis of intractable aspiration pneumonia.

The Relationship Between Lesion Localization and Dysphagia in Acute Stroke.

Factors that can facilitate early identification of individuals at risk of dysphagia such as stroke location are potentially of great benefit. The aim of this study was to examine the role of hemisphere and lesion location in assessing dysphagia pattern and airway invasion as identified through the use of validated, standardized interpretation measures for the videofluoroscopic swallowing study. Consecutive patients (N = 80) presenting with stroke symptoms who had a first-time acute ischemic stroke confirmed on diffusion-weighted magnetic resonance imaging (DW-MRI) scan participated. Three swallowing outcome variables were assessed using regression models: modified barium swallow impairment profile (MBSImP) oral impairment (OI) and pharyngeal impairment (PI) scores and penetration aspiration scale (PAS) score. Subjects were primarily male and demonstrated mild stroke and mild to moderate dysphagia. There was a significantly higher likelihood of abnormal PAS scores for infratentorial lesions compared to right hemisphere location (Odds ratio: 3.1, SE: 1.8, p = 0.046) and for Whites compared to African Americans (Odds ratio: 5.5, SE: 2.6, p = <0.001). However, OI scores were higher (worse) in African Americans compared to Whites (Beta = -1.2; SE: 0.56; p = 0.037). PI scores had no significant association with race or lesion location. Using DW-MRI to identify infratentorial stroke can help identify individuals at risk of airway invasion; however, imaging information concerning supratentorial infarct hemisphere and location may not be useful to predict which individuals with mild stroke are at risk for dysphagia and aspiration when admitted with acute stroke symptoms. Future studies should explore the role of race in the development of stroke-related dysphagia.

What Factors are Associated With 90-day Episode-of-care Payments for Younger Patients With Total Joint Arthroplasty?

BACKGROUND: Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-component differences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations. PURPOSE: (1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years. METHOD: Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments. RESULTS: The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients. CONCLUSION: Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable. LEVEL OF EVIDENCE: Level II, economic analysis.

Rapid Aspiration Screening for Suspected Stroke: Part 2: Initial and Sustained Nurse Accuracy and Reliability.

OBJECTIVE: To determine registered nurses' (RNs') ability to obtain and maintain accurate procedural skills and reliable interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. DESIGN: Prospective, observation study. SETTING: A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS: RNs (N=15) were recruited and trained in the administration and interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. INTERVENTIONS: RNs completed a total of 239 screenings of patients admitted with suspected stroke over a 2-year period. RNs administered the swallowing screening items and interpreted the patient's response to each item. Independent of the RN, a speech-language pathologist simultaneously interpreted the response of the participant with stroke to each swallowing screening item. MAIN OUTCOME MEASURES: Reliability of the interpretation and accuracy of the administration of the swallowing screening items. RESULTS: The average accuracy rate for the administration of the Rapid Aspiration Screening for Suspected Stroke was 98.33%, with the overall accuracy rate for each procedural task ranging from 95.42% to 100%. For the specific swallowing screening items that formed the Rapid Aspiration Screening for Suspected Stroke, dysarthria and a positive sign after water swallow, reliability was high (k=.817). The accuracy rate for the administration and reliability of the interpretation of the swallowing screening items improved as RNs gained experience, and both were maximized at 20 screening opportunities. CONCLUSIONS: RNs demonstrate both excellent accuracy of procedural administration and reliability of interpretation of the items of the Rapid Aspiration Screening for Suspected Stroke. With feedback and repeated opportunities to practice, maintenance of skills is achievable.