Surgical Treatment of Carotid-cavernous Fistula Performed through the Brazilian Unified Health System

Introduction The carotid-cavernous fistula (CCF) is an abnormal communication between the arterial carotid system and the cavernous sinus. In most cases, spontaneous fistulas are due to the rupture of intracavernous carotid artery aneurisms. Traumatic fistulas occur in 0.2% of head injuries, and 75% of all CCFs are caused by automobile accidents or penetrating traumas. Objective To identify the data regarding the number of annual procedures, hospital expenses, length of hospital stay, and the number of deaths of patients admitted by the Brazilian Unified Health System (SUS, in the Portuguese acronym), in the period between 2007 and 2017, using the surgical code of the surgical treatment for CCF. Methods The present was an ecological study whose data were obtained by consulting the database provided by the Department of Computer Sciences of the Brazilian Unified Health System (Datasus, in Portuguese). Results A total of 85 surgical procedures were performed for the treatment of CCFs from January 2007 to October 2017 through the Unified Health System (SUS, in Portuguese), and there was a reduction of 71.42% in this period. The annual incidence of patients undergoing this surgical treatment during the period observed remained low, with 1 case per 13,135,714 in 2007, and 1 case per 51,925,000 in 2017. Conclusion Despite the low annual incidence of the surgical treatment of CCFs performed by the SUS in Brazil in the period of 2007­2017, based on the data obtained on the average length of stay and expenditures in hospital services, it is necessary that we develop an adequate health planning.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions.

Importance: Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. Objective: To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. Design, Setting, and Participants: This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. Main Outcomes and Measures: Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. Results: Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. Conclusions and Relevance: Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Barriers for Ethnic Minorities and Low Socioeconomic Status Pediatric Patients for Behavioral Health Services and Benefits of an Integrated Behavioral Health Model.

The integrated behavioral health care model in primary care has the potential to reduce barriers to care experienced by children and families from ethnic minorities and low socioeconomic status. Limited access to pediatric behavioral health care is a significant problem, with up to 40% of children and adolescents with identified mental disorders and only 30% of them receiving care. Barriers include transportation, insurance, and shortage of specialists. Primary care provider bias, decreased knowledge and feelings of competence, and cultural beliefs and stigma also affect earlier diagnosis and treatment, particularly for Hispanic families with low English proficiency and African Americans.

Expenditures among young adults with acute lymphoblastic leukemia by site of care.

BACKGROUND: Individuals diagnosed with acute lymphoblastic leukemia (ALL) between the ages of 22 and 39 years experience worse outcomes than those diagnosed when they are 21 years old or younger. Treatment at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) mitigates these disparities but may be associated with higher expenditures. METHODS: Using deidentified administrative claims data (OptumLabs Data Warehouse), the cancer-related expenditures were examined among patients with ALL diagnosed between 2001 and 2014. Multivariable generalized linear model with log-link modeled average monthly health-plan-paid (HPP) expenditures and amount owed by the patient (out-of-pocket [OOP]). Cost ratios were used to calculate excess expenditures (CCC vs non-CCC). Incidence rate ratios (IRRs) compared CCC and non-CCC monthly visit rates. Models adjusted for sociodemographics, comorbidities, adverse events, and months enrolled. RESULTS: Clinical and sociodemographic characteristics were comparable between CCC (n = 160) and non-CCC (n = 139) patients. Higher monthly outpatient expenditures in CCC patients ($15,792 vs $6404; P < .001) were driven by outpatient hospital HPP expenditures. Monthly visit rates and per visit expenditures for nonchemotherapy visits (IRR = 1.6; P = .001; CCC = $8247, non-CCC = $1191) drove higher outpatient hospital expenditures among CCCs. Monthly OOP expenditures were higher at CCCs for outpatient care (P = .02). Inpatient HPP expenditures were significantly higher at CCCs ($25,918 vs $13,881; ꞵ = 0.9; P < .001) before accounting for adverse events but were no longer significant after adjusting for adverse events (ꞵ = 0.4; P = .1). Hospitalizations and length of stay were comparable. CONCLUSIONS: Young adults with ALL at CCCs have higher expenditures, likely reflecting differences in facility structure, billing practices, and comprehensive patient care. It would be reasonable to consider CCCs comparable to the oncology care model and incentivize the framework to achieve superior outcomes and long-term cost savings. LAY SUMMARY: Health care expenditures in young adults (aged 22-39 years) with acute lymphoblastic leukemia (ALL) are higher among patients at National Cancer Institute-designated Comprehensive Cancer Centers (CCC) than those at non-CCCs. The CCC/non-CCC differences are significant among outpatient expenditures, which are driven by higher rates of outpatient hospital visits and outpatient hospital expenditures per visit at CCCs. Higher expenditures and visit rates of outpatient hospital visits among CCCs may also reflect how facility structure and billing patterns influence spending or comprehensive care. Young adults at CCCs face higher inpatient HPP expenditures; these are driven by serious adverse events.

Practice-site-level measures of primary care comprehensiveness and their associations with patient outcomes.

OBJECTIVES: To develop two practice-site-level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician-level measures. DATA SOURCES: Medicare fee-for-service claims. STUDY DESIGN: We calculated practice-site-level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices' attributed beneficiaries' 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs' comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice-site and PCP-level measures with outcomes. PRINCIPAL FINDINGS: The measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P < .01). Receiving primary care from a practice at the 75th versus 25th percentile on the new problem management measure was associated with $14.77 (1.9%) lower total Medicare expenditures per beneficiary per month (P < .05); 8.84 (3.0%) fewer hospitalizations (P < .001), and 21.27 (3.1%) fewer ED visits per thousand beneficiaries per year (P < .01). PCP comprehensiveness varied more within than between practices. CONCLUSIONS: More comprehensive primary care practices had lower Medicare FFS expenditures, hospitalization, and ED visit rates. Both PCP and practice-site level comprehensiveness measures had strong construct and predictive validity; PCP-level measures were more precise.

Recommendations to Improve Payment Policies for Comprehensive Dementia Care.

Access to comprehensive dementia care is limited. Recent changes in billing for professional services, including new physician fee schedule codes, encourage clinicians to provide new services; however, current reimbursement does not cover costs for all needed elements of dementia care. The Payment Model for Comprehensive Dementia Care Conference convened more than 50 national experts from diverse perspectives to review promising strategies for payment reform including ways to accelerate their adoption. Recommendations for reform included payments for services to family caregivers; new research to determine success metrics; education for consumers, providers, and policymakers; and advancing a population health model approach to tier coverage based on risk and need within a health system.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE: We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model. DATA SOURCES: We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas. STUDY DESIGN: We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR. PRINCIPAL FINDINGS: Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant. CONCLUSIONS: When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Bridging the gap: an economic case study of the impact and cost effectiveness of comprehensive healthcare intermediaries in rural Mexico.

BACKGROUND: In rural settings where patients face significant structural barriers to accessing healthcare services, the formal existence of government-provided health coverage does not necessarily translate to meaningful care delivery. This paper analyses the effectiveness of an innovative approach to overcome these barriers, the Right to Health Care programme offered by Compañeros en Salud in Chiapas, Mexico. This programme provides comprehensive free coverage of all additional direct and indirect medical costs as well as accompaniment through the medical system. Over 550 patients had participated from 2013 until November 2018. METHODS: Focusing on ten of the most frequently treated conditions, including hernias, cataracts and congenital heart defects, we performed a retrospective case study analysis of the quality-adjusted life years (QALYs) gained from treatment and the cost per QALY for 69 patients. This analysis used disability weights and uncertainty intervals from the Global Burden of Disease study and organisational micro-costing data for each patient. Each patient was compared to their own hypothetical counterfactual health outcome had they not received the secondary and tertiary care required for the specific condition. A mixed methods approach is used to establish this counterfactual baseline, drawing on pre-intervention observations, qualitative interviews and established literature precedent. RESULTS: The programme was found to deliver an average of 14.4 additional QALYs (95% uncertainty interval 12.4-15.8) without time discounting. The mean cost per QALY over these conditions was $388 USD (95% UI $262-588) at purchasing power parity. CONCLUSIONS: These numbers compare favourably with studies of other health services and international cost per QALY guidelines. They reflect the on-treatment effect for the ten conditions analysed and are presented as a case study indicative of the promise of healthcare intermediaries rather than a definitive assessment of cost-effectiveness. Nonetheless, these results show the potential feasibility and cost effectiveness of a more comprehensive approach to healthcare provision in a resource-limited rural setting. TRIAL REGISTRATION: This study involves economic analysis of a programme facilitating access to public healthcare services. Thus, there was no associated clinical trial to be registered.

The UK haemophilia specialist nurse: Competencies fit for practice in the 21st century.

INTRODUCTION: Nurses play a central co-ordinating role in delivering comprehensive care for people with haemophilia and allied bleeding disorders, for which they need a broad range of competencies. The UK Haemophilia Nurses Association (HNA) published a role description in 1994 which was developed into a competency framework in 2014. This has now been updated to reflect current educational and clinical practice. AIM: To summarize the evidence supporting the nurse's advanced role within haemophilia care and develop new competencies to deliver comprehensive care within a multidisciplinary team. METHODS: Systematic reviews were identified by PubMed literature search. The HNA conducted workshops to consult its membership, and the authors incorporated this input to update its competency framework within the structure outlined by Health Education England in multiprofessional framework for advanced clinical practice in England (2017). RESULTS: The proposed framework includes five domains (Clinical knowledge, Clinical/direct care, Communication and support, Collaborative practice and Research) supported by indicators for four levels of practice (beginner, competent, proficient and expert). The framework is a tool which nurses and their managers can use to assess skills and knowledge, and identify learning needs appropriate to personal development and improve patient care and outcomes. CONCLUSION: The HNA has developed a new competency framework to provide a strong foundation for haemophilia specialist nurses to continue improving services for people living with bleeding disorders and their families, as well as supporting personal development alongside new therapeutic options, models of care and follow-up.

Association of Organizational Factors and Physician Practices' Participation in Alternative Payment Models.

Importance: Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation. Objective: To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices. Design, Setting, and Participants: A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019. Exposures: Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors. Main Outcomes and Measures: Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts. Results: A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation. Conclusions and Relevance: Greater APM participation appears to be supported by integration and system ownership.

Implementation of the comprehensive care for joint replacement model: A post-acute physical therapy case report.

Background: The Centers for Medicare and Medicaid services has specifically targeted total joint replacements with a retrospective bundled payment program called the Comprehensive Care for Joint Replacement (CJR) model to improve collaboration between providers and decrease costs associated with the surgery and subsequent rehabilitation. The purpose of this report is to describe the physical therapy post-acute episode of care of a patient receiving services under the CJR model and illustrate the impact of facility policy changes on physical therapy service delivery, length of stay, cost of care, and patient outcomes in a post-acute environment. Case Description: The patient was a 78-year-old woman who underwent an elective total knee arthroplasty (TKA). She had moderate mobility impairments (total activities of daily living [ADL] score of 6) and was a high fall risk as scored by the Physical Mobility Scale and Tinetti Mobility Test, respectively. Physical therapy interventions focused on exercises to decrease activity limitations and participation restrictions. Outcomes: The patient demonstrated significant improvements in physical function after 22 total physical therapy visits spanning her Skilled Nursing Facility and subsequent outpatient treatment resulting in an intrafacility cost reduction of 52%. Compared with the average number of visits and costs for post-acute care following a TKA, this patient's care, under the CJR model, involved less cost and required fewer visits. Conclusions: This case report supports some of the proposed benefits of the CJR model for Medicare beneficiaries undergoing TKA.

Aggregating Claims Data Across Payers: Approaches, Challenges, and Lessons Learned From the Comprehensive Primary Care Initiative.

The Comprehensive Primary Care (CPC) initiative fueled the emergence of new organizational alliances and financial commitments among payers and primary care practices to use data for performance improvement. In most regions of the country, practices received separate confidential feedback reports of claims-based measures from multiple payers, which varied in content and provided an incomplete picture of a practice's patient panel. Over CPC's last few years, participating payers in several regions resisted the tendency to guard data as a proprietary asset, instead working collaboratively to produce aggregated performance feedback for practices. Aggregating claims data across payers is a potential game changer in improving practice performance because doing so potentially makes the data more accessible, comprehensive, and useful. Understanding lessons learned and key challenges can help other initiatives that are aggregating claims or clinical data across payers for primary care practices or other types of providers.

Clinical and economic analysis of patients with acute myeloid leukemia by FLT3 status and midostaurin use at a Comprehensive Cancer Center.

INTRODUCTION: Identification of cytogenetic and molecular abnormalities has become vital for the appropriate treatment of acute myeloid leukemia (AML). One of the most common molecular alterations in AML is the constitutive activation by internal tandem duplication of FMS-like tyrosine kinase 3 (FLT3). METHODS: This observational, retrospective, cohort study at the Huntsman Cancer Institute (HCI) had two time periods: 1) a historical pre-midostaurin time period which consisted of the FLT3 mutated (FLT3m) and FLT3 wild type (FLT3wt) cohorts from January 1, 2007, to December 31, 2016, and 2) a post-midostaurin cohort which consisted of the FLT3 mutated midostaurin-user cohort (early mido) from May 01, 2017 to December 31, 2018. RESULTS: In total, 39 patients were included in the FLT3m cohort, 61 in the FLT3wt cohort, and seven in the early mido cohort. FLT3m patients spent fewer days in the hospital during the first consolidation regimen and received fewer consolidation cycles compared to FLT3wt patients. Overall survival (OS) was similar between FLT3m and FLT3wt patients. For patients without hematopoietic stem cell transplant, OS was significantly shorter for FLT3m patients compared to FLT3wt patients. Mean AML related inpatient charges and physician charges for FLT3m patients were significantly higher than FLT3wt patients. CONCLUSION: The FLT3 mutation is historically associated with a shorter time to transplant and increased total health care charges. More information is needed to evaluate the real-world treatment strategies for FLT3-mutated patients in the presence of FLT3 inhibitors and the impact of these treatment strategies on clinical and economic outcomes.

Effect of Comprehensive Care Coordination on Medicaid Expenditures Compared With Usual Care Among Children and Youth With Chronic Disease: A Randomized Clinical Trial.

Importance: Medicaid spending on children and young adults with chronic disease could be decreased through care coordination programs by reducing unnecessary hospital and emergency care. Objective: To assess whether a comprehensive care coordination program reduces Medicaid expenditures by decreasing hospital and emergency department (ED) utilization. Design, Setting, and Participants: This randomized clinical trial included 6259 children and young adults with chronic disease who received public insurance through Illinois Medicaid. In April 2016, eligible youth were randomized to receive comprehensive care coordination through the Coordinated Healthcare for Complex Kids (CHECK) program (n = 3126) or usual care (n = 3119) to measure the effect of the CHECK program on Medicaid expenditures and health care utilization using a difference-in-differences (DID) approach. Data were collected from May 1, 2014, to April 30, 2017, and analyzed in May 2018. Interventions: Care coordination, mental health care, education, and social support were provided to CHECK participants and their family members. Services were tailored based on family and participant need. Main Outcomes and Measures: Mean annual Medicaid expenditures, mean annual health care utilization by category (ED and inpatient), and chronic disease type and risk level. Results: A total of 6259 participants (mean [SD] age, 11.3 [6.4] years; 2918 [46.6%] female; 2594 [41.4%] with medium and high risk) were randomized. Following the exclusion of 14 outliers, 6245 participants were analyzed. The mean (SD) annual Medicaid expenditure before the intervention was $1633 ($4006) for the intervention group and $1703 ($4466) for the usual care group, which decreased to a mean (SD) of $1341 ($3004) and $1413 ($3785), respectively, after the intervention (DID, -$1; 95% CI, -$199 to $196; P = .99). The mean (SD) inpatient utilization before the intervention was 63.0 (344.4) per 1000 person-years (PYs) for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention (DID, 2.0; 95% CI, -17.9 to 21.8; P = .85). Among participants with asthma, those in the intervention group had a greater mean (SD) decrease in ED utilization compared with usual care, but the difference was not significant (-225.9 [65.3] vs -104.5 [80.0] visits per 1000 PY; DID, -121.5; 95% CI, -268.9 to 26.0; P = .11). Similarly, enrolled participants with sickle cell disease had a smaller but not significant mean (SD) increase in ED utilization compared with usual care (583.3 [839.0] vs 3761.9 [4611.2] visits per 1000 PYs; DID, -3178.6; 95% CI, -10 724.3 to 4367.2; P = .41). Conclusions and Relevance: Overall Medicaid expenditures and health care utilization (hospital and ED) decreased similarly for both CHECK participants and the usual care group. Trial Registration: ClinicalTrials.gov identifier: NCT04057521.

Examining Cost Measurements in Production and Delivery of Three Case Studies Using E-Learning for Applied Health Sciences: Cross-Case Synthesis.

BACKGROUND: The World Health Report (2006) by the World Health Organization conveys that a significant increase is needed in global health care resourcing to meet the current and future demand for health professionals. Electronic learning (e-Learning) presents a possible opportunity to change and optimize training by providing a scalable means for instruction, thus reducing the costs for training health professionals and providing patient education. Research literature often suggests that a benefit of e-Learning is its cost-effectiveness compared with face-to-face instruction, yet there is limited evidence with respect to the comparison of design and production costs with other forms of instruction or the establishment of standards pertaining to budgeting for these costs. OBJECTIVE: To determine the potential cost favorability of e-Learning in contrast to other forms of learning, there must first be an understanding of the components and elements for building an e-Learning course. Without first taking this step, studies lack the essential financial accounting rigor for course planning and have an inconsistent basis for comparison. This study aimed to (1) establish standard ingredients for the cost of e-Learning course production and (2) determine the variance instructional design has on the production costs of e-Learning courses. METHODS: This study made use of a cross-case method among 3 case studies using mixed methods, including horizontal budget variance calculation and qualitative interpretation of responses from course designers for budget variance using total quality management themes. The different implementation-specific aspects of these cases were used to establish common principles in the composition of budgets in the production and delivery of an applied health professional e-Learning course. RESULTS: A total of 2 case studies reported significant negative budget variances caused by issues surrounding underreporting of personnel costs, inaccurate resource task estimation, lack of contingency planning, challenges in third-party resource management, and the need to update health-related materials that became outdated during course production. The third study reported a positive budget variance because of the cost efficiency derived from previous implementation, the strong working relationship of the course project team, and the use of iterative project management methods. CONCLUSIONS: This research suggests that the delivery costs of an e-Learning course could be underestimated or underreported and identifies factors that could be used to better control budgets. Through consistent management of factors affecting the cost of course production, further research could be undertaken using standard economic evaluation methods to evaluate the advantages of using e-Learning.

No Changes in Patient Selection and Value-Based Metrics for Total Hip Arthroplasty After Comprehensive Care for Joint Replacement Bundle Implementation at a Single Center.

BACKGROUND: Alternative payment models for total hip arthroplasty (THA) were initiated by the Center for Medicare and Medicaid Services to decrease overall healthcare cost. The associated shift of financial risk to participating institutions may negatively influence patient selection to avoid high cost of care ("cherry picking," "lemon dropping"). This study evaluated the impact of the Comprehensive Care for Joint Replacement (CJR) model on patient selection, care delivery, and hospital costs at a single care center. METHODS: Patients undergoing a primary THA from 2015-2017 were stratified by insurance type (Medicare and commercial insurance) and whether care was provided before (pre-CJR) or after (post-CJR) CJR bundle implementation. Patient age, gender, and body mass index, Elixhauser comorbidities and American Society of Anesthesiologists scores, were analyzed. Delivery of care variables including surgery duration, discharge disposition, length of stay, and direct hospital costs were compared pre- and post-CJR. RESULTS: A total of 751 THA patients (273 Medicare and 478 commercial Insurance) were evaluated pre-CJR (29%) and post-CJR (71%). Patient demographics were similar (age, gender, BMI); however, commercially insured patients had less comorbidities pre-CJR (P = .033). Medicare patient post-CJR length of stay (P = .010) was reduced with a trend toward discharge to home (P = .019). Surgical time, operating room service time, 90-day readmissions and direct hospital costs were similar pre- and post-CJR. CONCLUSION: There was no differential patient selection after CJR bundle implementation and value-based metrics (surgical time, operating room service time) were not affected. Patients were discharged sooner and more often to home. However, overall direct hospital expenses remained unchanged revealing that any cost savings were for insurance providers, not participating hospitals.

Care Transformation Collaborative of Rhode Island: Building a Strong Foundation for Comprehensive, High-Quality Affordable Care.

As the Patient Centered Medical Home (PCMH) model has evolved nationally and in Rhode Island, there has been increased recognition that PCMH has not been sufficient to achieve desired cost and quality goals. In this article, we describe the evolving concept of "comprehensive primary care" in Rhode Island, which includes addressing the behavioral health and social determinants of health (SDOH) needs of patients. These needs are identified through systematic screening and dedicated care management and care coordination for patients who present with complex needs.