Bundled payments lead to quality improvements in hospitals' skilled nursing facility referral networks.

OBJECTIVES: To assess whether hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program for joint replacement changed their referral patterns to favor higher-quality skilled nursing facilities (SNFs). STUDY DESIGN: Retrospective observational study using 2009-2015 inpatient and outpatient claims from a 20% sample of Medicare beneficiaries undergoing joint replacement in US hospitals (N = 146,074) linked with data from Medicare's BPCI program and Nursing Home Compare. METHODS: We ran fixed effect regression models regressing BPCI participation on hospital-SNF referral patterns (number of SNF discharges, number of SNF partners, and SNF referral concentration) and SNF quality (facility inspection survey rating, patient outcome rating, staffing rating, and registered nurse staffing rating). RESULTS: We found that BPCI participation was associated with a decrease in the number of SNF referrals and no significant change in the number of SNF partners or concentration of SNF partners. BPCI participation was associated with discharge to SNFs with a higher patient outcome rating by 0.04 stars (95% CI, 0.04-0.26). BPCI participation was not associated with improvements in discharge to SNFs with a higher facility survey rating (95% CI, -0.03 to 0.11), staffing rating (95% CI, -0.07 to 0.04), or registered nurse staffing rating (95% CI, -0.09 to 0.02). CONCLUSIONS: BPCI participation was associated with lower volume of SNF referrals and small increases in the quality of SNFs to which patients were discharged, without narrowing hospital-SNF referral networks.

Papers and patents are becoming less disruptive over time.

Theories of scientific and technological change view discovery and invention as endogenous processes1,2, wherein previous accumulated knowledge enables future progress by allowing researchers to, in Newton's words, 'stand on the shoulders of giants'3-7. Recent decades have witnessed exponential growth in the volume of new scientific and technological knowledge, thereby creating conditions that should be ripe for major advances8,9. Yet contrary to this view, studies suggest that progress is slowing in several major fields10,11. Here, we analyse these claims at scale across six decades, using data on 45 million papers and 3.9 million patents from six large-scale datasets, together with a new quantitative metric-the CD index12-that characterizes how papers and patents change networks of citations in science and technology. We find that papers and patents are increasingly less likely to break with the past in ways that push science and technology in new directions. This pattern holds universally across fields and is robust across multiple different citation- and text-based metrics1,13-17. Subsequently, we link this decline in disruptiveness to a narrowing in the use of previous knowledge, allowing us to reconcile the patterns we observe with the 'shoulders of giants' view. We find that the observed declines are unlikely to be driven by changes in the quality of published science, citation practices or field-specific factors. Overall, our results suggest that slowing rates of disruption may reflect a fundamental shift in the nature of science and technology.

Care fragmentation predicts 90-day durable ventricular assist device outcomes.

OBJECTIVES: To examine whether fragmentation of care is associated with worse in-hospital and 90-day outcomes following durable ventricular assist device (VAD) implant. STUDY DESIGN: Cohort study. METHODS: This study was conducted using Medicare claims linked to the Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) among patients undergoing VAD implant between July 2009 and April 2017. Medicare data were used to measure fragmentation of the multidisciplinary care delivery network for the treating hospital, based on providers' history of shared patients within the previous year. STS Intermacs data were used for risk adjustment and outcomes ascertainment. Hospitals were sorted into terciles based on the degree of network fragmentation, measured as the mean number of links separating providers in the network. Multivariable regression was used to associate network fragmentation with 90-day death or infection risk. RESULTS: The cohort included 5159 patients who underwent VAD implant, with 11.2% dying and 27.6% experiencing an infection within 90 days after implant. After adjustment, a 1-unit increase in network fragmentation was associated with an increase of 0.179 in the probability of in-hospital infection and an increase of 0.183 in the probability of 90-day infection (both P < .05). Similar results were observed in models of the numbers of in-hospital and 90-day infections. Network fragmentation was predictive of the probability of 90-day mortality, although this relationship was not significant after adjustment. CONCLUSIONS: Care delivery network fragmentation is associated with higher in-hospital and 90-day infection rates following durable VAD implant. These networks may serve as novel targets for enhancing outcomes for patients undergoing VAD implant.

Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset.

BACKGROUND: Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS: Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections. RESULTS: The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (ß=16032.5, p=0.008). CONCLUSIONS: Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.

Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery.

BACKGROUND: Accountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients. OBJECTIVE: To determine whether such informal clinical integration relates to a health system's performance in an ACO. RESEARCH DESIGN: We analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physicians delivered care to them, we aggregated across episodes to construct physician networks for each health system. We used network analysis to measure each system's level of informal clinical integration (defined by cross-specialty ties). We fit regression models to examine the association between a health system's CABG mortality rate and ACO participation, conditional on informal clinical integration. SUBJECTS: Beneficiaries age 66 and older undergoing CABG. MEASURES: Ninety-day CABG mortality. RESULTS: Over the study period, 3385 beneficiaries were treated in 161 ACO-participating health systems. The remaining 49,854 were treated in 875 nonparticipating systems or one of the 161 ACO-participating systems before the ACO start date. ACO systems with higher levels of informal clinical integration had lower CABG mortality rates than nonparticipating ones (2.8% versus 5.5%; P<0.01); however, there was no difference based on ACO participation for health systems with lower to relatively moderate informal clinical integration. Regression results corroborate this finding (coefficient for interaction between ACO participation and informal clinical integration level is -0.25; P=0.01). CONCLUSIONS: Formal clinical integration through ACO participation may be insufficient to improve outcomes. Health systems with higher informal clinical integration may benefit more from ACO participation.

Coordination of Care Around Surgery for Colon Cancer: Insights From National Patterns of Physician Encounters With Medicare Beneficiaries.

PURPOSE: To improve care coordination for complex cancers, it is critical to establish a more nuanced understanding of the types of providers involved. As the number of provider types increases, strategies to support cancer care coordination must adapt to a greater variety of information needs, communication styles, and treatment strategies. METHODS: We categorized providers into 11 types, using National Provider Identifier specialties. Using Medicare claims, we counted the number of unique combinations of provider types billed during preoperative, operative, and postdischarge care for colon cancer surgery and assessed how this count varies across hospitals. The study included 70,567 beneficiaries in fee-for-service Medicare A and B for 6 months before and 60 days after an admission for colectomy for colon cancer between 2008 and 2011. RESULTS: We observed 1,554 preoperative provider-type combinations, 975 operative combinations, and 1,571 postdischarge combinations. The three most common combinations in the preoperative phase were general medicine only, other medical specialists only, and general medicine and other medical specialists. In the operative phase, the three most common combinations were primary surgery, anesthesiology, and pathology; general medicine, other medical specialists, radiology, primary surgery, anesthesiology, and pathology; and other medical specialists, radiology, primary surgery, anesthesiology, and pathology. In the postdischarge phase, the three most common combinations were general medicine, general medicine and other medical specialists, and general medicine and oncology. On average, each hospital had 15 preoperative, 11 operative, and 15 postoperative combinations. High-volume, larger, teaching, urban, and noncritical access hospitals had more combinations in all phases. CONCLUSION: Many provider-type combinations are involved in colon cancer surgery care. Substantial variation exists across hospitals types, suggesting that certain hospitals need additional resources and more flexible infrastructure to coordinate care.

Physician referral patterns and racial disparities in total hip replacement: A network analysis approach.

BACKGROUND: Efforts to reduce racial disparities in total hip replacement (THR) have focused mainly on patient behaviors. While these efforts are no doubt important, they ignore the potentially important role of provider- and system-level factors, which may be easier to modify. We aimed to determine whether the patterns of interaction among physicians around THR episodes differ in communities with low versus high concentrations of black residents. MATERIALS AND METHODS: We analyzed national Medicare claims from 2008 to 2011, identifying all fee-for-service beneficiaries who underwent THR. Based on physician encounter data, we then mapped the physician referral networks at the hospitals where beneficiaries' procedures were performed. Next, we measured two structural properties of these networks that could affect care coordination and information sharing: clustering, and the number of external ties. Finally, we estimated multivariate regression models to determine the relationship between the concentration of black residents in the community [as measured by the hospital service area (HSA)] served by a given network and each of these 2 network properties. RESULTS: Our sample included 336,506 beneficiaries (mean age 76.3 ± SD), 63.1% of whom were women. HSAs with higher concentrations of black residents tended to be more impoverished than those with lower concentrations. While HSAs with higher concentrations of black residents had, on average, more acute care beds and medical specialists, they had fewer surgeons per capita than those with lower concentrations. After adjusting for these differences, we found that HSAs with higher concentrations of black residents were served by physician referral networks that had significantly higher within-network clustering but fewer external ties. CONCLUSIONS: We observed differences in the patterns of interaction among physicians around THR episodes in communities with low versus high concentrations of black residents. Studies investigating the impact of these differences on access to quality providers and on THR outcomes are needed.

Association of Informal Clinical Integration of Physicians With Cardiac Surgery Payments.

Importance: To reduce inefficiency and waste associated with care fragmentation, many current programs target greater clinical integration among physicians. However, these programs have led to only modest Medicare spending reductions. Most programs focus on formal integration, which often bears little resemblance to actual physician interaction patterns. Objectives: To examine how physician interaction patterns vary between health systems and to assess whether variation in informal integration is associated with care delivery payments. Design, Setting, and Participants: National Medicare data from January 1, 2008, through December 31, 2011, identified 253 545 Medicare beneficiaries (aged ≥66 years) from 1186 health systems where Medicare beneficiaries underwent coronary artery bypass grafting (CABG) procedures. Interactions were mapped between all physicians who treated these patients-including primary care physicians and surgical and medical specialists-within a health system during their surgical episode. The level of informal integration was measured in these networks of interacting physicians. Multivariate regression models were fitted to evaluate associations between payments for each surgical episode made on a beneficiary's behalf and the level of informal integration in the health system where the patient was treated. Exposures: The informal integration level of a health system. Main Outcomes and Measures: Price-standardized total surgical episode and component payments. Results: The total 253 545 study participants included 175 520 men (69.2%; mean [SD] age, 74.51 [5.75] years) and 78 024 women (34.3%; 75.67 [5.91] years). One beneficiary of the 253 545 participants did not have sex information. The low level of informal clinical integration included 84 598 patients (33.4%; mean [SD] age, 75.00 [5.93] years); medium level, 84 442 (33.30%; 74.94 [5.87] years); and high level, 84 505 (33.34%; 74.66 [5.72] years) (P < .001). Informal integration levels varied across health systems. After adjusting for patient, health-system, and community factors, higher levels of informal integration were associated with significantly lower total episode and component payments (ß coefficients for informal integration were -365.87 [95% CI, -451.08 to -280.67] for total episode payments, -182.63 [-239.80 to -125.46] for index hospitalization, -43.13 [-55.53 to -30.72] for physician services, -74.48 [-103.45 to -45.51] for hospital readmissions, and -62.04 [-88.00 to -36.07] for postacute care; P < .001 for each association). When beneficiaries were treated in health systems with higher informal integration, the greatest savings of lower estimated payments were from hospital readmissions (13.0%) and postacute care services (5.8%). Conclusions and Relevance: Informal integration is associated with lower spending. Although most programs that seek to promote clinical integration are focused on health systems' formal structures, policy makers may also want to address informal integration.

Repeated, Close Physician Coronary Artery Bypass Grafting Teams Associated with Greater Teamwork.

OBJECTIVE: To determine whether observed patterns of physician interaction around shared patients are associated with higher levels of teamwork as perceived by physicians. DATA SOURCES/STUDY SETTING: Michigan Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) procedures at 24 hospitals in the state between 2008 and 2011. STUDY DESIGN: We assessed hospital teamwork using the teamwork climate scale in the Safety Attitudes Questionnaire. After aggregating across CABG discharges at these hospitals, we mapped the physician referral networks (including both surgeons and nonsurgeons) that served them and measured three network properties: (1) reinforcement, (2) clustering, and (3) density. We then used multilevel regression models to identify associations between network properties and teamwork at the hospitals on which the networks were anchored. PRINCIPAL FINDINGS: In hospitals where physicians repeatedly cared for patients with the same colleagues, physicians perceived better teamwork (ß-reinforcement = 3.28, p = .003). When physicians who worked together also had other colleagues in common, the reported teamwork was stronger (ß clustering = 1.71, p = .001). Reported teamwork did not change when physicians worked with a higher proportion of other physicians at the hospital (ß density = -0.58, p = .64). CONCLUSION: In networks with higher levels of reinforcement and clustering, physicians perceive stronger teamwork, perhaps because the strong ties between them create a shared understanding; however, sharing patients with more physicians overall (i.e., density) did not lead to stronger teamwork. Clinical and organizational leaders may consider designing the structure of clinical teams to increase interactions with known colleagues and repeated interactions between providers.

Association Between Physician Teamwork and Health System Outcomes After Coronary Artery Bypass Grafting.

BACKGROUND: Patients undergoing coronary artery bypass grafting (CABG) must often see multiple providers dispersed across many care locations. To test whether teamwork (assessed with the bipartite clustering coefficient) among these physicians is a determinant of surgical outcomes, we examined national Medicare data from patients undergoing CABG. METHODS AND RESULTS: Among Medicare beneficiaries who underwent CABG between 2008 and 2011, we mapped relationships between all physicians who treated them during their surgical episodes, including both surgeons and nonsurgeons. After aggregating across CABG episodes in a year to construct the physician social networks serving each health system, we then assessed the level of physician teamwork in these networks with the bipartite clustering coefficient. Finally, we fit a series of multivariable regression models to evaluate associations between a health system's teamwork level and its 60-day surgical outcomes. We observed substantial variation in the level of teamwork between health systems performing CABG (SD for the bipartite clustering coefficient was 0.09). Although health systems with high and low teamwork levels treated beneficiaries with comparable comorbidity scores, these health systems differed over several sociocultural and healthcare capacity factors (eg, physician staff size and surgical caseload). After controlling for these differences, health systems with higher teamwork levels had significantly lower 60-day rates of emergency department visit, readmission, and mortality. CONCLUSIONS: Health systems with physicians who tend to work together in tightly-knit groups during CABG episodes realize better surgical outcomes. As such, delivery system reforms focused on building teamwork may have positive effects on surgical care.

Differences between physician social networks for cardiac surgery serving communities with high versus low proportions of black residents.

BACKGROUND: Compared with white patients, black patients are more likely to undergo cardiac surgery at low-quality hospitals, even when they live closer to high-quality ones. Opportunities for organizational interventions to alleviate this problem remain elusive. OBJECTIVES: To explore physician isolation in communities with high proportions of black residents as a factor contributing to racial disparities in access to high-quality hospitals for cardiac surgery. RESEARCH DESIGN: Using national Medicare data (2008-2011), we mapped physician social networks at hospitals where coronary artery bypass grafting procedures were performed, measuring their degree of connectedness. We then fitted a series of multivariate regression models to examine for associations between physician connectedness and the proportion of black residents in the hospital service area (HSA) served by each network. MEASURES: Measures of physician connectedness (ie, repeat-tie fraction, clustering, and number of external ties). RESULTS: After accounting for regional differences in healthcare capacity, the social networks of physicians practicing in areas with more black residents varied in many important respects from those of HSAs with fewer black residents. Physicians serving HSAs with many black residents had a smaller number of repeated interactions with each other than those in other HSAs (P<0.001). When these physicians did interact, they tended to assemble in smaller groups of highly interconnected colleagues (P<0.001). They also had fewer interactions with physicians outside their immediate geographic area (P=0.048). CONCLUSIONS: Physicians in HSAs with many black residents are more isolated than those in HSAs with fewer black residents. This isolation may negatively impact on care coordination and information sharing. As such, planned delivery system reforms that encourage minorities to seek care within their established local networks may further exacerbate existing surgical disparities.

Assessing the reach of health reform to outpatient surgery with social network analysis.

OBJECTIVE: To assess the proportion of outpatient surgery currently delivered in ambulatory surgery centers (ASCs) unconnected to nearby hospitals. BACKGROUND: The ASC as a site for outpatient surgery represents one of the fastest growing sectors in health care. Because most are freestanding, ASCs may have little connection to local health systems, possibly placing them outside health reform's reach. METHODS: Using all-payer data from Florida (2005-2009), we identified all ASCs and hospitals active in the state. Using the tools of social network analysis, we then measured each ASC's strength of connection to nearby hospitals on the basis of the number of surgeons shared between facilities. Finally, we determined the proportion of all procedures and charges accounted for by (1) ASCs that are strongly connected to their local health system, (2) those that are weakly connected, and (3) those that are unconnected. RESULTS: Of the 1.4 million procedures performed in Florida ASCs each year, fewer than 250,000 occur at unconnected and weakly connected ASCs. Put differently, 83% of the $4.3 billion in charges for ASC-based care originate from facilities that have substantial integration with their local health system. Although weakly and strongly connected ASCs are similar from an organizational perspective, unconnected ones tend to focus on a single specialty (P = 0.026) and are staffed by fewer physicians (P = 0.013). Furthermore, there is a trend toward fewer unconnected ASCs over time (P = 0.080). CONCLUSIONS: Most ASCs are strongly connected to their local health system. Thus, efforts to constrain spending should target population-based rates of surgery, not unconnected ASCs.