Comparison of Payment Margins Between the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement Model Shows a Marked Reduction for a Successful Program.

BACKGROUND: The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. METHODS: The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. RESULTS: The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. CONCLUSIONS: These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A computerized reminder system improves compliance with Papanicolaou smear recommendations in an HIV care clinic.

Current guidelines call for Papanicolaou (Pap) smear screening of HIV-infected women at least annually. After the initiation of a weekly computer based Pap smear reminder list in an HIV care clinic, the prevalence of scheduled women with up-to-date Pap smears was calculated for the one-year project period and was compared to the prevalence preceding the project. The prevalence of scheduled women with up-to-date Pap smears increased from 61.4% to 73.2% (P <0.001) during the project period. Including Pap smears that were performed elsewhere, the final up-to-date Pap smear rate was 82.7%. The improved rate of up-to-date Pap smears showed no sign of attenuation over time. A computerized report generated from data in the hospital information system increased rates of compliance with Pap smear screening recommendations. Creative utilization of hospital data environments may be an inexpensive route to improved compliance with practice guidelines.

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

OBJECTIVE: To evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study. MATERIALS AND METHODS: In phase 1, from May to August 2010, the effectiveness of a 'retract-and-reorder' measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an 'ID-verify alert', and an 'ID-reentry function'. RESULTS: The retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71). DISCUSSION AND CONCLUSION: Wrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.