Assessing Patterns of Telehealth Use Among People with Sickle Cell Disease Enrolled in Medicaid During the Start of the COVID-19 Pandemic.

Background: Telehealth can be defined as using remote technologies to provide health care. It may increase access to care among people with sickle cell disease (SCD). This study examined (1) telehealth use, (2) characteristics of telehealth use, and (3) differences between telehealth users and nonusers among people with SCD during the COVID-19 pandemic. Methods: This was a retrospective analysis of Medicaid claims among four states [California (CA), Georgia (GA), Michigan (MI), Tennessee (TN)] participating in the Sickle Cell Data Collection program. Study participants were individuals ≥1 year old with SCD enrolled in Medicaid September 2019-December 2020. Telehealth encounters during the pandemic were characterized by provider specialty. Health care utilization was compared between those who did (users) and did not (nonusers) use telehealth, stratified by before and during the pandemic. Results: A total of 8,681 individuals with SCD (1,638 CA; 3,612 GA; 1,880 MI; and 1,551 TN) were included. The proportion of individuals with SCD that accessed telehealth during the pandemic varied across states from 29% in TN to 80% in CA. During the pandemic, there was a total of 21,632 telehealth encounters across 3,647 users. In two states (MI and GA), over a third of telehealth encounters were with behavioral health providers. Telehealth users had a higher average number of health care encounters during the pandemic: emergency department (pooled mean = 2.6 for users vs. 1.5 for nonusers), inpatient (1.2 for users vs. 0.6 for nonusers), and outpatient encounters (6.0 for users vs. 3.3 for nonusers). Conclusions: Telehealth was frequently used at the beginning of the COVID-19 pandemic by people with SCD. Future research should focus on the context, facilitators, and barriers of its implementation in this population.

Paravertebral block for percutaneous nephrolithotomy: a prospective, randomized, double-blind placebo-controlled study.

PURPOSE: Percutaneous nephrolithotomy (PCNL) is performed commonly in patients with large kidney stones, but the management of their postoperative pain presents a major challenge. While it is not routinely performed in PCNL patients, paravertebral block (PVB) has been described as an effective strategy for pain control after various non-urologic surgeries. This trial aims to assess the effect of paravertebral blockade on intraoperative and postoperative opioid use as well as postoperative pain control in patients undergoing PCNL. METHODS: This was a prospective, randomized, double-blind, placebo-controlled study. Patients who consented to participate were randomly assigned to undergo either PVB or a placebo intervention preoperatively. The patient, surgeon, and anesthesia team were all blinded to the randomization. The outcome parameters were intraoperative opioid requirement, postoperative visual analog scale (VAS) pain scores, postoperative opioid use, and postoperative antiemetic use. RESULTS: 23 patients were enrolled in each arm of the study, and the two groups had no significant differences in baseline demographic or clinical characteristics. Patients in the PVB group had significantly lower intraoperative opioid use, postoperative opioid use, frequency of opioid use, and antiemetic. Patients in the PVB group also had lower postoperative VAS pain scores. There were no patients who suffered from complications attributable to PVB. CONCLUSION: The results of this randomized, double-blind, placebo-controlled trial suggest that PVB should be considered an effective strategy to reduce opioid requirement and improve pain control for patients undergoing PCNL.

Impact of Clinical Guidelines on Voiding Cystourethrogram Use and Vesicoureteral Reflux Incidence.

PURPOSE: To prevent over diagnosis and overtreatment of vesicoureteral reflux the 2007 NICE (National Institute for Health and Care Excellence) and 2011 AAP (American Academy of Pediatrics) guidelines recommended against routine voiding cystourethrograms in children presenting with first febrile urinary tract infections. The impact of these guidelines on clinical practice is unknown. MATERIALS AND METHODS: Using an administrative claims database (Clinformatics™ Data Mart) children who underwent voiding cystourethrogram studies or had a diagnosis of vesicoureteral reflux between 2001 and 2015 were identified. The cohort was divided into children age 0 to 2 and 3 to 10 years. Single and multiple group interrupted time series analyses (difference-in-difference) were performed with the guidelines as intervention points. The incidence of vesicoureteral reflux was compared across each period. RESULTS: Of the 51,649 children who underwent voiding cystourethrograms 19,422 (38%) were diagnosed with vesicoureteral reflux. In children 0 to 2 years old voiding cystourethrogram use did not decrease after the 2007 NICE guidelines were announced (-0.37, 95% CI -1.50 to 0.77, p = 0.52) but did decrease significantly after the 2011 AAP guidelines were announced (-2.00, 95% CI -3.35 to -0.65, p = 0.004). Among children 3 to 10 years old voiding cystourethrogram use decreased during the entire study period. There was a decrease in the incidence of vesicoureteral reflux in both groups that mirrored patterns of voiding cystourethrogram use. CONCLUSIONS: The 2011 AAP guidelines led to a concurrent decrease in voiding cystourethrogram use and incidence of vesicoureteral reflux among children 0 to 2 years old. Further studies are needed to assess the risks and benefits of reducing the diagnosis of vesicoureteral reflux in young children.

Postoperative Atrial Fibrillation Predicts Long-Term Cardiovascular Events after Radical Cystectomy.

PURPOSE: Postoperative atrial fibrillation after radical cystectomy occurs in 2% to 8% of cases. Recent evidence suggests that transient postoperative atrial fibrillation leads to future cardiovascular events. The long-term cardiovascular implications of postoperative atrial fibrillation in patients undergoing radical cystectomy are largely unknown. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida were used to identify patients who underwent radical cystectomy between 2007 and 2010. After excluding patients with a history of atrial fibrillation, coronary artery disease and/or stroke, patients were matched using propensity scoring on age, race, insurance status and preexisting comorbidities. Adjusted Kaplan-Meier time-to-event analysis and Cox proportional hazards models were used to assess the effect of postoperative atrial fibrillation on cardiovascular events (acute myocardial infarction and stroke) during postoperative year 1. RESULTS: Radical cystectomy was performed in 4,345 patients who met the study inclusion criteria, of whom 210 (4.8%) had postoperative atrial fibrillation. There was a significantly higher cumulative incidence of cardiovascular events during the first postoperative year in patients in whom postoperative atrial fibrillation developed (24.8% vs 10.9%, adjusted log rank p=0.007). Cox proportional hazards regression demonstrated an increased risk of cardiovascular events in patients with postoperative atrial fibrillation (HR 10, p=0.02). CONCLUSIONS: Our results demonstrate that patients undergoing radical cystectomy in whom transient postoperative atrial fibrillation develops are at significantly increased risk for cardiovascular events in the first postoperative year. Physicians should be vigilant in assessing postoperative atrial fibrillation, even when transient, and establish appropriate followup given the increased risk of cardiovascular morbidity.

Insurance Expansion and the Utilization of Inpatient Surgery: Evidence for a "Woodwork" Effect?

INTRODUCTION: The impact of insurance expansion on the currently insured population is largely unknown. We examine rates of elective surgery in previously insured individuals before and after Massachusetts health care reform. METHODS: Using the State Inpatient Databases for Massachusetts and 2 control states (New York and New Jersey) that did not expand coverage, we identified patients aged 69 and older who underwent surgery from January 1, 2003, through December 31, 2010. We studied 5 elective operations (knee and hip replacement, transurethral resection of prostate, inguinal hernia repair, back surgery). We examined statewide utilization rates before and after implementation of health care reform, using a difference-in-differences technique to adjust for secular trends. We also performed subgroup analyses according to race and income strata. RESULTS: We observed no increase in the overall rate of selected discretionary inpatient surgeries in Massachusetts versus control states for the entire population (-1.4%, P = .41), as well as among the white (-1.6%, P = .43) and low-income (-2.2%, P = .26) subgroups. We did, however, find evidence for a woodwork effect in the subgroup of nonwhite elderly patients, among whom the rate of these procedures increased by 20.5% (P = .001). Among nonwhites, the overall result reflected increased utilization of all 5 individual procedures, with statistically significant changes for knee replacement (18%, P < .01), back surgery (18%, P = .05), transurethral resection of the prostate (28%, P = .05), and hernia repair (71%, P = .03). CONCLUSION: Our findings suggest that national insurance expansion may increase the use of elective surgery among subgroups of previously insured patients.

New modalities for evaluation and surveillance of complex renal cysts.

PURPOSE: The increased use of abdominal imaging has led to more frequent detection of incidental renal cysts. Since the inception of the Bosniak classification system, management of Bosniak I, III and IV cysts has been clearly defined, while evaluation and management of Bosniak II and IIF cysts have remained a clinical dilemma. Discussions of new imaging modalities are becoming increasingly prevalent in the radiological literature. In this context we performed a comprehensive review of the recent literature on complex renal cysts focusing on new imaging modalities, surveillance strategies and biopsy. MATERIALS AND METHODS: We performed a comprehensive literature review of articles published from January 1, 1998 through December 31, 2013 via MEDLINE(®), EMBASE and the Cochrane Collection using a predetermined search strategy. All studies included were performed in humans older than 18 years, were written in English and had an abstract available for review. We grouped studies into 1 of 5 categories, ie computerized tomography, magnetic resonance imaging, ultrasound, biopsy and surveillance. RESULTS: While computerized tomography and magnetic resonance imaging with and without contrast enhancement remain the gold standard to evaluate cystic lesions of the kidney, diffusion-weighted magnetic resonance imaging and contrast enhanced ultrasound have surfaced as new tools for assessment of complex cysts. Comparative effectiveness studies on these new imaging modalities are limited. Image guided biopsy has increasingly been shown to be useful for evaluation of intermediate (Bosniak II and IIF) complex cysts. We found few studies providing guidance on the duration and/or intensity of surveillance required for intermediate complex renal cysts. CONCLUSIONS: Although new and enhanced techniques are in development and may be useful in the future management of complex renal cysts, there is a paucity of data regarding the value of these new techniques. Future research should focus on surveillance of intermediate complex renal cysts, particularly on the ideal frequency and type of imaging required.

Five-year experience with metallic stents for chronic ureteral obstruction.

PURPOSE: We present 5 years of outcome data on metallic ureteral stents in a cohort of patients treated for chronic ureteral obstruction. MATERIALS AND METHODS: We retrospectively identified and analyzed the records of all patients in whom a Resonance® Metallic Ureteral Stent was placed between early 2007 and late 2011 at our institution. We performed a descriptive analysis of key outcomes, including the failure and death rates, and stenting duration, defined as the time from initial stent placement to last stent failure or patient death. We also performed a secondary comparative analysis of patients with a benign vs malignant etiology of obstruction. RESULTS: A total of 139 metallic stents were placed in 47 patients, including 27 (57%) with malignant and 20 (43%) with a benign etiology. Of the patients 15 (32%) had bilateral obstruction. Maximum followup was 59 months (mean 20, median 13, IQR 4-31). Stent failure occurred in 13 patients (28%), including 4 in the benign and 9 in the malignant group (p = 0.35). The median duration of stenting for benign and malignant obstruction was 22 (IQR 9-39) vs 7 months (IQR 3-25) (p = 0.106). Stenting duration was equivalent when controlling for the higher death rate in the malignant group. CONCLUSIONS: Resonance metallic stents are an adequate management strategy for benign and malignant ureteral obstruction. A subset of patients in each group continued to do well at more than a 3-year overall duration of stenting. Failure rates were similar for benign and malignant etiologies.

Online reviews of 500 urologists.

PURPOSE: Patient demand for easily accessible information about physician quality has led to the development of physician review websites. These sites concern some physicians who argue that ratings can be misleading. In this study we describe the landscape of online reviews of urologists by looking at a sample of ratings and written reviews from popular physician review websites. MATERIALS AND METHODS: A total of 500 urologists were randomly selected from a database of 9,940. Numerical ratings from 10 popular physician review websites were collected for each physician and analyzed. Written reviews from a single physician review website were also collected and then categorized as extremely negative/positive, negative/positive or neutral. RESULTS: Our sample consisted of 471 male and 29 female urologists from 39 states including small and large cities and 4 census regions. There were 398 (79.6%) urologists who had at least 1 rating on any of the 10 physician review websites (range 0 to 64). On average the composite rating was based on scores from only 2.4 submitted ratings. Most physicians had positive ratings (86%), with 36% having highly positive ratings. No difference was seen in the median number of reviews when gender (p = 0.72), region (p = 0.87) and city size (p = 0.87) were compared. Written reviews were mostly positive or extremely positive (53%). CONCLUSIONS: We advise physicians and patients to be aware that most urologists are rated on at least 1 physician review website, and while most ratings and reviews are favorable, composite scores are typically based on a small number of reviews and, therefore, can be volatile.

Proton therapy for prostate cancer online: patient education or marketing?

INTRODUCTION: Proton therapy (PT) for prostate cancer is an expensive treatment with limited evidence of benefit over conventional radiotherapy. We sought to study whether online information on PT for prostate cancer was balanced and whether the website source influenced the content presented. MATERIALS AND METHODS: We applied a systematic search process to identify 270 weblinks associated with PT for prostate cancer, categorized the websites by source, and filtered the results to 50 websites using predetermined criteria. We then used a customized version of the DISCERN instrument, a validated tool for assessing the quality of consumer health information, to evaluate the remaining websites for balance of content and description of risks, benefits and uncertainty. RESULTS: Depending on the search engine and key word used, proton center websites (PCWs) made up 10%-47% of the first 30 encountered links. In comparison, websites from academic and nonacademic medical centers without ownership stake in proton centers appeared much less frequently as a search result (0%-3%). PCWs scored lower on DISCERN questions compared to other sources for being balanced/unbiased (p < 0.001), mentioning areas of uncertainty (p < 0.001), and describing risks of PT (p < 0.001). PCWs scored higher for describing the benefits of treatment (p = 0.003). CONCLUSIONS: Patients should be aware that online information regarding PT for prostate cancer may represent marketing by proton centers rather than comprehensive and unbiased patient education. An awareness of these results will also better prepare clinicians to address the potential biases of patients with prostate cancer who search the Internet for health information.

A unique complication of urethral catheterization: pubic hair associated with struvite bladder calculi.

Bladder stones account for 5% of all urinary stone disease and can develop on a foreign body, such as a misplaced suture, eroded surgical mesh, or ureteral stent. In this case study, the authors present a patient with bladder stones associated with pubic hairs introduced during a monthly indwelling Foley catheter change. Clinicians have an important role in instructing patients on the use of proper technique and hygiene practices during urethral catheterization to minimize the potential for urinary complications.

Readability of websites containing information about prostate cancer treatment options.

PURPOSE: Approximately 90 million American adults have literacy skills that test below a high school reading level. Websites written above this level can pose a challenge for those seeking online information about prostate cancer treatment options. In this study we determine the readability of selected websites using a systematic search process and validated readability formulas. MATERIALS AND METHODS: We identified the 3 most popular keywords from 513 terms related to prostate cancer treatment options. We then systematically collected 270 websites from the top 3 search engines, and excluded from study those that were nonEnglish, not primarily text, irrelevant and/or duplicated. We used the Flesch-Kincaid grade level and Flesch Reading Ease to determine scores for each site. RESULTS: A total of 62 unique websites were analyzed. Median Flesch-Kincaid grade level was 12.0 (range 8.0 to 12.0) and median Flesch Reading Ease score was 38.1 (range 0.0 to 65.5). Only 3 sites (4.8%) were written below a high school reading level (less than 9.0). CONCLUSIONS: Few websites with discussions on prostate cancer treatment options are written below a high school reading level. This is problematic for a third of Americans who seek to further educate themselves using online resources. Clinicians can use this information to guide their patients to appropriate websites.

Age, race, insurance type, and digital divide index are associated with video visit completion for patients seen for oncologic care in a large hospital system during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic drove rapid adoption of telehealth across oncologic specialties. This revealed barriers to telehealth access and telehealth-related disparities. We explored disparities in telehealth access in patients with cancer accessing oncologic care. MATERIALS/METHODS: Data for all unique patient visits at a large academic medical center were acquired pre- and intra-pandemic (7/1/2019-12/31/2020), including visit type (in-person, video, audio only), age, race, ethnicity, rural/urban (per zip code by Federal Office of Rural Health Policy), distance from medical facility, insurance, and Digital Divide Index (DDI; incorporates technology/internet access, age, disability, and educational attainment metrics by geographic area). Pandemic phases were identified based on visit dynamics. Multivariable logistic regression models were used to examine associations of these variables with successful video visit completion. RESULTS: Data were available for 2,398,633 visits for 516,428 patients across all specialties. Among these, there were 253,880 visits from 62,172 patients seen in any oncology clinic. Dramatic increases in telehealth usage were seen during the pandemic (after 3/16/2020). In multivariable analyses, patient age [OR: 0.964, (95% CI 0.961, 0.966) P<0.0001], rural zip code [OR: 0.814 (95% CI 0.733, 0.904) P = 0.0001], Medicaid enrollment [OR: 0.464 (95% CI 0.410, 0.525) P<0.0001], Medicare enrollment [OR: 0.822 (95% CI 0.761, 0.888) P = 0.0053], higher DDI [OR: 0.903 (95% CI 0.877, 0.930) P<0.0001], distance from the facility [OR: 1.028 (95% CI 1.021, 1.035) P<0.0001], black race [OR: 0.663 (95% CI 0.584, 0.753) P<0.0001], and Asian race [OR: 1.229 (95% CI 1.022, 1.479) P<0.0001] were associated with video visit completion early in the pandemic. Factors related to video visit completion later in the pandemic and within sub-specialties of oncology were also explored. CONCLUSIONS: Patients from older age groups, those with minority backgrounds, and individuals from areas with less access to technology (high DDI) as well as those with Medicare or Medicaid insurance were less likely to use video visits. With greater experience through the pandemic, disparities were not mitigated. Further efforts are required to optimize telehealth to benefit all patients and avoid increasing disparities in care delivery.

Association Between Delivery System Structure and Intensity of End-of-Life Cancer Care.

PURPOSE: To determine whether the type of delivery system is associated with intensity of care at the end of life for Medicare beneficiaries with cancer. PATIENTS AND METHODS: We used SEER registry data linked with Medicare claims to evaluate intensity of end-of-life care for patients who died of one of ten common cancers diagnosed from 2009 through 2014. Patients were categorized as receiving the majority of their care in an integrated delivery system, designated cancer center, health system that was both integrated and a certified cancer center, or health system that was neither. We evaluated adherence to seven nationally endorsed end-of-life quality measures using generalized linear models across four delivery system types. RESULTS: Among 100,549 beneficiaries who died of cancer during the study interval, we identified only modest differences in intensity of end-of-life care across delivery system structures. Health systems with no cancer center or integrated affiliation demonstrated higher proportions of patients with multiple hospitalizations in the last 30 days of life (11.3%), death in an acute care setting (25.9%), and lack of hospice use in the last year of life (31.6%; all P < .001). Patients enrolled in hospice had lower intensity care across multiple end-of-life quality measures. CONCLUSION: Intensity of care at the end of life for patients with cancer was higher at delivery systems with no integration or cancer focus. Maximal supportive care delivered through hospice may be one avenue to reduce high-intensity care at the end of life and may impact quality of care for patients dying from cancer.

Temporary Health Impact of Prostate MRI and Transrectal Prostate Biopsy in Active Surveillance Prostate Cancer Patients.

PURPOSE: To assess the temporary health impact of prostate multiparametric MRI (mpMRI) and transrectal prostate biopsy in an active surveillance prostate cancer population. METHODS: A two-arm institutional review board-approved HIPAA-compliant prospective observational patient-reported outcomes study was performed from November 2017 to July 2018. Inclusion criteria were men with Gleason 6 prostate cancer in active surveillance undergoing either prostate mpMRI or transrectal prostate biopsy. A survey instrument was constructed using validated metrics in consultation with the local patient- and family-centered care organization. Study subjects were recruited at the time of diagnostic testing and completed the instrument by phone 24 to 72 hours after testing. The primary outcome measure was summary testing-related quality of life (summary utility score), derived from the testing morbidities index (TMI) (scale: 0 = death and 1 = perfect health). TMI is stratified into seven domains, with each domain scored from 1 (no health impact) to 5 (extreme health impact). Testing-related quality-of-life measures in the two cohorts were compared with Mann-Whitney U test. RESULTS: In all, 122 subjects were recruited, and 90% (110 of 122 [MRI 55 of 60, biopsy 55 of 62]) successfully completed the survey instrument. The temporary quality-of-life impact of transrectal biopsy was significantly greater than that of prostate mpMRI (0.82, 95% confidence interval [CI] 0.79-0.85, versus 0.95, 95% CI 0.94-0.97; P < .001). The largest mean domain-level difference was for intraprocedural pain (transrectal biopsy 2.6, 95% CI 2.4-2.8, versus mpMRI 1.3, 95% CI 1.1-1.5; P < .001). CONCLUSION: Transrectal prostate biopsy has greater temporary health impact (lower testing-related quality-of-life measure) than prostate mpMRI.

Variation in payments for spine surgery episodes of care: implications for episode-based bundled payment.

OBJECTIVE Spine surgery is expensive and marked by high variation across regions and providers. Bundled payments have potential to reduce unwarranted spending associated with spine surgery. This study is a cross-sectional analysis of commercial and Medicare claims data from January 2012 through March 2015 in the state of Michigan. The objective was to quantify variation in payments for spine surgery in adult patients, document sources of variation, and determine influence of patient-level, surgeon-level, and hospital-level factors. METHODS Hierarchical regression models were used to analyze contributions of patient-level covariates and influence of individual surgeons and hospitals. The primary outcome was price-standardized 90-day episode payments. Intraclass correlation coefficients-measures of variability accounted for by each level of a hierarchical model-were used to quantify sources of spending variation. RESULTS The authors analyzed 17,436 spine surgery episodes performed by 195 surgeons at 50 hospitals. Mean price-standardized 90-day episode payments in the highest spending quintile exceeded mean payments for episodes in the lowest cost quintile by $42,953 (p < 0.001). Facility payments for index admission and post-discharge payments were the greatest contributors to overall variation: 39.4% and 32.5%, respectively. After accounting for patient-level covariates, the remaining hospital-level and surgeon-level effects accounted for 2.0% (95% CI 1.1%-3.8%) and 4.0% (95% CI 2.9%-5.6%) of total variation, respectively. CONCLUSIONS Significant variation exists in total episode payments for spine surgery, driven mostly by variation in post-discharge and facility payments. Hospital and surgeon effects account for relatively little of the observed variation.

Effects of the Medicare Modernization Act on Spending for Outpatient Surgery.

OBJECTIVES: To examine the effects of Medicare's revised ambulatory surgery center (ASC) payment schedule on overall payments for outpatient surgery. DATA SOURCES: Twenty percent sample of national Medicare beneficiaries. STUDY DESIGN: We conducted a pre-post study of Medicare beneficiaries who underwent outpatient surgery in a hospital outpatient department (HOPD), ASC, or physician office between 2004 and 2011. Specifically, we used multivariable regression to compare temporal trends in outpatient surgery before and after implementation of Medicare's revised payment schedule in 2008, which reduced ASC facility payments to roughly two-thirds that of HOPDs. Our outcome measures included overall Medicare payments, utilization rates, per beneficiary spending, and average episode payments for outpatient surgery. PRINCIPAL FINDINGS: Between the last quarters of 2007 and 2008, overall Medicare payments for outpatient surgery grew by $334 million-an amount nearly three times higher than would have been expected without the policy change (p < .001 for the difference). While utilization rates of outpatient surgery were attenuated, per beneficiary spending and average surgical episode payments increased by 10.4 percent and 7.8 percent, respectively, over the same period. By the end of 2011, Medicare payments for outpatient surgery reached $5.1 billion. Without the policy change, they would have totaled only $4.1 billion. CONCLUSIONS: Despite lessening demand, reduced ASC facility payments did not curb spending for outpatient surgery. In fact, overall payments actually increased following the policy change, driven by higher average episode payments.

Sprint to work: A novel model for team science collaboration in academic medicine.

Collaborative research in academic medicine is often inefficient and ineffective. It often fails to leverage the expertise of interdisciplinary team members, does not seek or incorporate team input at opportune times, and creates workload inequities. Adapting approaches developed in venture capital, we created the 'sprint model' for writing academic papers based on the analysis of secondary data. The 'sprint model' minimizes common barriers that undermine collaboration in academic medicine. This model for team science collaboration begins with team members convening for a highly focused, guided session. In this session, a facilitator moves the group through a structured process to create the study plan. This includes refining the research questions, developing the study design, and prototyping the presentation of results. After adopting this model, our team has drastically reduced time from idea inception to final product submission through increased efficiencies and reduced redundancies. From December 2016 to April 2018, our team has initiated 15 paper sprints. The median time from sprint to submission for paper sprints has been 1.7 months (minimum: 0.5; maximum: 9). Although our current 'sprint' approach has already demonstrated a substantial improvement in our ability to rapidly produce high-quality research, we believe the 'pre-sprint' preparation and 'post-sprint' processes can be further refined. Finally, we discuss the limitations of this model and our efforts to adapt the process to meet the evolving needs of research teams.

Risk Adjustment May Lessen Penalties On Hospitals Treating Complex Cardiac Patients Under Medicare's Bundled Payments.

To reduce variation in spending, Medicare has considered implementing a cardiac bundled payment program for acute myocardial infarction and coronary artery bypass graft. Because the proposed program does not account for patient risk factors when calculating hospital penalties or rewards ("reconciliation payments"), it might unfairly penalize certain hospitals. We estimated the impact of adjusting for patients' medical complexity and social risk on reconciliation payments for Medicare beneficiaries hospitalized for the two conditions in the period 2011-13. Average spending per episode was $29,394. Accounting for medical complexity substantially narrowed the gap in reconciliation payments between hospitals with high medical severity (from a penalty of $1,809 to one of $820, or a net reduction of $989), safety-net hospitals (from a penalty of $217 to one of $87, a reduction of $130), and minority-serving hospitals (from a penalty of $70 to a reward of $56, an improvement of $126) and their counterparts. Accounting for social risk alone narrowed these gaps but had minimal incremental effects after medical complexity was accounted for. Risk adjustment may preserve incentives to care for patients with complex conditions under Medicare bundled payment programs.

Understanding pre-enrollment surgical outcomes for hospitals participating in Medicare Accountable Care Organizations.

BACKGROUND: To anticipate the effects of accountable care organizations (ACOs) on surgical care, we examined pre-enrollment utilization, outcomes, and costs of inpatient surgery among hospitals currently enrolled in Medicare ACOs vs nonenrolling facilities. METHODS: Using the Nationwide Inpatient Sample (2007 to 2011), we compared patient and hospital characteristics, distributions of surgical specialty care, and the most common inpatient surgeries performed between ACO-enrolling and nonenrolling hospitals before implementation of Medicare ACOs. We used multivariable regression to compare pre-enrollment inpatient mortality, length of stay (LOS), and costs. RESULTS: Hospitals now participating in Medicare ACO programs were more frequently nonprofit (P < .001) and teaching institutions (P = .01) that performed more specialty procedures (P < .001). We observed no clinically meaningful pre-enrollment differences for inpatient mortality, prolonged length of stay, or costs for procedures performed at ACO-enrolling vs nonenrolling hospitals. CONCLUSIONS: Medicare ACO hospitals had pre-enrollment outcomes that were similar to nonparticipating facilities. Future studies will determine whether ACO participation yields differential changes in surgical quality or costs.

Telemedicine in Urology: State of the Art.

Whereas telemedicine is recognized as one of the fastest-growing components of the healthcare system, the status of telemedicine use in urology is largely unknown. In this narrative review, we detail studies that investigate the use of televisits and teleconsultations for urologic conditions. Moreover, we discuss current regulatory and reimbursement policies. Finally, we discuss the significant barriers to widespread dissemination and implementation of telemedicine and reasons why the field of urology may be positioned to become a leader in the provision of telemedicine services.