Until It's a regulation It's not my fight: Complexities of a voluntary nonlead hunting ammunition program.

Wildlife and human health are at risk of lead exposure from spent hunting ammunition. Lead exposure persists for bald eagles due to bullet fragments in game animal gut piles and unretrieved carcasses, and is also a human health risk when wild game is procured using lead ammunition. Programs encouraging the voluntary use of nonlead ammunition have become a popular approach mitigating these effects. This study explored attitudes and experiences of United States Fish and Wildlife Service (USFWS) staff implementing an outreach program encouraging deer hunters to voluntary use nonlead ammunition on 54 National Wildlife Refuges (NWRs) in the Upper Midwest, U.S. to understand factors affecting program implementation. We conducted 29 semi-structured interviews of USFWS staff along with 60 responses from an open-ended survey question. Twelve themes emerged from the data and were grouped into three broad categories: (1) challenges of dealing with complex issues, (2) importance of messengers and messages, and (3) resistance from staff. Challenges of dealing with complex issues included administrative restraint and uncertainty, scope and scale of program, human health not an agency responsibility, contextual political influences, and public-private collaborations. Importance of messengers and messages included the importance of experience, and salience of human health risk. Finally, resistance from staff included skepticism of the science and motives behind the program, competing priorities for refuge staff, differing perceptions of regulatory and voluntary approaches, cost and availability of nonlead ammunition, and disregard by some about lead ammunition and human health risks. Staff identified numerous challenges implementing the program, many of which were external factors beyond the control of the participants. Understanding the factors affecting program implementation may help guide future efforts encouraging the voluntary use of nonlead ammunition.

Description and Impact of a Comprehensive Multispecialty Multidisciplinary Intervention to Decrease Opioid Prescribing in Surgery.

INTRODUCTION: Diversion of excess prescription opioids contributes to the opioid epidemic. We sought to describe and study the impact of a comprehensive departmental initiative to decrease opioid prescribing in surgery. METHODS: A multispecialty multidisciplinary initiative was designed to change the culture of postoperative opioid prescribing, including: consensus-built opioid guidelines for 42 procedures from 11 specialties, provider-focused posters displayed in all surgical units, patient opioid/pain brochures setting expectations, and educational seminars to residents, advanced practice providers, residents and nurses. Pre- (April 2016-March 2017) versu post-initiative (April 2017-May 2018) analyses of opioid prescribing at discharge [median oral morphine equivalent (OME)] were performed at the specialty, prescriber, patient, and procedure levels. Refill prescriptions within 3 months were also studied. RESULTS: A total of 23,298 patients were included (11,983 pre-; 11,315 post-initiative). Post-initiative, the median OME significantly decreased for 10 specialties (all P values < 0.001), the percentage of patients discharged without opioids increased from 35.7% to 52.5% (P < 0.001), and there was no change in opioids refills (0.07% vs 0.08%, P = 0.9). Similar significant decreases in OME were observed when the analyses were performed at the provider and individual procedure levels. Patient-level analyses showed that the preinitiative race/sex disparities in opioid-prescribing disappeared post-initiative. CONCLUSION: We describe a comprehensive multi-specialty intervention that successfully reduced prescribed opioids without increase in refills and decreased sex/race prescription disparities.

The Presence of Scarring and Associated Morbidity in the Burn Model System National Database.

INTRODUCTION: Postburn scarring is common, but the risk factors, natural history, and consequences of such scars are still poorly understood. This study aims to describe the frequency of scar-related morbidity for up to 2 years after injury and to analyze the impact of burn scars on long-term functional, psychosocial, and reintegration outcomes. METHODS: Analysis was conducted on data collected between January 2006 and May 2014 from 960 patients (2440 anatomic burn sites) using the Burn Model System (BMS) database. Study population demographics were analyzed and odds ratios for the development of raised or thick scarring were determined. Regression analyses were used to evaluate the impact of hypertrophic scarring (HTS) on psychosocial outcomes, including the Community Integration Questionnaire, Satisfaction with Life Scale, Distress, and the Short Form 12. Symptoms associated with scarring were analyzed at discharge and 6, 12, and 24 months after burn using a set of questions on scarring developed by the BMS. Mixed-effect modeling was used to determine linear change over time and the significance of symptoms. RESULTS: The study population was primarily white (65.0%) and male (71.8%), with a mean (SD) age of 44.0 (15.2) years and mean total body surface area burned of 19.6% (17.9%). The incidence of raised or thick scars increased from 65% to 80% (P < 0.0001) for the 2-year follow-up period. The presence of scarring was not associated with Community Integration Questionnaire, Satisfaction with Life Scale, or Short Form 12 scores. Most patients reported symptoms associated with scarring at 2 years after burn, including dry or fragile skin, scars that restrict range of motion at a joint, issues with hand function, and scar pain and itch. CONCLUSIONS: In this large, longitudinal, multicenter cohort of burn survivors, nearly all patients noted the presence of scarring, and a majority noted additional symptoms and morbidity related to their scars even at 2 years after injury. This study demonstrates a need for the continued support of burn survivors to address scar-related morbidity. Furthermore, future studies examining the impact of novel treatments for scarring should use similar scar problem questionnaires and distress scores.

Spending Patterns Among Medicare ACOs That Have Reduced Costs.

EXECUTIVE SUMMARY: This study aimed to examine whether specific cost categories were disproportionately affected by accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) achieving overall spending reductions, and whether there were demonstrable differences in spending patterns between "low"- or "high"-cost ACOs. Using financial data obtained from the Centers for Medicare & Medicaid Services for ACOs launched between 2012 and 2015, and employing a cross-sectional study design, we determined which cost categories were associated with overall reductions in ACO spending. Linear regressions were conducted to discern whether reductions in inpatient and skilled nursing facility (SNF) costs were driven by reductions in the number of admissions or in the cost per admission. Results showed that ACOs that reduced total per capita spending saw the largest percentage decreases in inpatient (-9%), hospice (-11%), and SNF (-16%) per capita costs, compared to ACOs that were unable to decrease costs between 2014 and 2015 (p < .05). Reductions in SNF and inpatient spending were driven by declines in the number of patients admitted, not the cost per hospitalization or SNF admission (p < .05). In 2015, ACOs in the highest decile of per capita spending spent more than double on each beneficiary compared to ACOs in the lowest decile ($16,672 versus $8,030, respectively; p < .05). ACOs in the lowest-cost decile spent more proportionally on outpatient and physician/supplier costs (p < .05). Thus, we determined that initial success in reducing the cost of care has been driven by reductions in inpatient costs due to a decline in the volume of patients admitted. Future studies should further investigate specific interventions that allow high-performing ACOs to achieve these cost reductions.

The Legal Limit: Differences in Injury Severity Score for Vehicular Crashes.

In 2013, the National Transportation Safety Board advised lawmakers in the United States to reduce the legal limit of blood alcohol content (BAC) from 0.08% to 0.05%. The purpose of this research was to evaluate the rationale for reducing the legal limit of BAC to 0.05% through analysis of the relationship between BAC and injury severity. A correlational study was conducted on patients with positive BAC involved in a motor vehicular collision. Retrospective review of 446 trauma patients (aged 18-80 years) injured in a vehicular collision routinely screened for BAC was conducted. Two groups were compared: Group 1, patients with nonzero blood alcohol concentration (n = 101); and Group 2, patients with zero blood alcohol (n = 345). Standard statistical analyses were utilized. A total of 101 patients (23%) had a detectable BAC on admission. Patients with a detectable BAC were younger (33 and 44 years) and more likely to be male (27% and 16%). There was no statistically significant association between both injury severity score (ISS) and BAC or between ISS and age. There was no significant correlation between higher BAC and a higher ISS. Positive BAC alone may not affect ISS, but the potential for risk-taking behaviors by drivers under the influence may increase injury severity.

The Student Curriculum Review Team: How we catalyze curricular changes through a student-centered approach.

Student feedback is a valuable asset in curriculum evaluation and improvement, but many institutions have faced challenges implementing it in a meaningful way. In this article, we report the rationale, process and impact of the Student Curriculum Review Team (SCRT), a student-led and faculty-supported organization at the Johns Hopkins University School of Medicine. SCRT's evaluation of each pre-clinical course is composed of a comprehensive three-step process: a review of course evaluation data, a Town Hall Meeting and online survey to generate and assess potential solutions, and a thoughtful discussion with course directors. Over the past two years, SCRT has demonstrated the strength of its approach by playing a substantial role in improving medical education, as reported by students and faculty. Furthermore, SCRT's uniquely student-centered, collaborative model has strengthened relationships between students and faculty and is one that could be readily adapted to other medical schools or academic institutions.

Fractional CO2 Laser for Burn Scars: A Comparison of Patient Reported Outcomes Between Those With and Without Laser Treatment.

Burn reconstruction outcomes are an area of growing investigation. Although there is evidence of measured physical improvements in scar characteristics after laser treatment, there is little information on patient reported outcomes. The purpose of this study is to compare patient reported outcomes between burn survivors with and without laser treatment. The study included participants in the Burn Model Systems National Database at a single center; participants that received outpatient laser treatment for burn scars were compared to a matched group of burn survivors that did not receive laser. The following outcomes were examined: Satisfaction With Life Scale, Mental and Physical Component Summary of the Veterans Rand Survey, and the PROMIS Pain Intensity Scale. Regression analyses examined the associations between laser treatment and each outcome at 12 and 24 months. The study population included 287 adult burn survivors (65 laser group, 222 control group). The significant differences found between the two groups included: burn size (laser: 14.9, 13.5 SD, control: 8.9, 11.1 SD; p<0.001), insurance type (p=0.036), inhalation injury (laser: 17.2%, control: 2.7%; p<0.001), and ventilator requirement (laser: 27.7%, control: 13.5%; p=0.013). Laser treatment was not associated with any of the outcomes at both follow-up time points. Further research is needed to develop patient reported outcome measures that are more sensitive to the clinical changes experienced by burn survivors receiving laser treatment.

Lead poisoning of raptors: state of the science and cross-discipline mitigation options for a global problem.

Lead poisoning is an important global conservation problem for many species of wildlife, especially raptors. Despite the increasing number of individual studies and regional reviews of lead poisoning of raptors, it has been over a decade since this information has been compiled into a comprehensive global review. Here, we summarize the state of knowledge of lead poisoning of raptors, we review developments in manufacturing of non-lead ammunition, the use of which can reduce the most pervasive source of lead these birds encounter, and we compile data on voluntary and regulatory mitigation options and their associated sociological context. We support our literature review with case studies of mitigation actions, largely provided by the conservation practitioners who study or manage these efforts. Our review illustrates the growing awareness and understanding of lead exposure of raptors, and it shows that the science underpinning this understanding has expanded considerably in recent years. We also show that the political and social appetite for managing lead ammunition appears to vary substantially across administrative regions, countries, and continents. Improved understanding of the drivers of this variation could support more effective mitigation of lead exposure of wildlife. This review also shows that mitigation strategies are likely to be most effective when they are outcome driven, consider behavioural theory, local cultures, and environmental conditions, effectively monitor participation, compliance, and levels of raptor exposure, and support both environmental and human health.

A PREVENTIVE TOOL FOR PREDICTING BLOODSTREAM INFECTIONS IN CHILDREN WITH BURNS.

ABSTRACT: Introduction: Despite significant advances in pediatric burn care, bloodstream infections (BSIs) remain a compelling challenge during recovery. A personalized medicine approach for accurate prediction of BSIs before they occur would contribute to prevention efforts and improve patient outcomes. Methods: We analyzed the blood transcriptome of severely burned (total burn surface area [TBSA] ≥20%) patients in the multicenter Inflammation and Host Response to Injury ("Glue Grant") cohort. Our study included 82 pediatric (aged <16 years) patients, with blood samples at least 3 days before the observed BSI episode. We applied the least absolute shrinkage and selection operator (LASSO) machine-learning algorithm to select a panel of biomarkers predictive of BSI outcome. Results: We developed a panel of 10 probe sets corresponding to six annotated genes ( ARG2 [ arginase 2 ], CPT1A [ carnitine palmitoyltransferase 1A ], FYB [ FYN binding protein ], ITCH [ itchy E3 ubiquitin protein ligase ], MACF1 [ microtubule actin crosslinking factor 1 ], and SSH2 [ slingshot protein phosphatase 2 ]), two uncharacterized ( LOC101928635 , LOC101929599 ), and two unannotated regions. Our multibiomarker panel model yielded highly accurate prediction (area under the receiver operating characteristic curve, 0.938; 95% confidence interval [CI], 0.881-0.981) compared with models with TBSA (0.708; 95% CI, 0.588-0.824) or TBSA and inhalation injury status (0.792; 95% CI, 0.676-0.892). A model combining the multibiomarker panel with TBSA and inhalation injury status further improved prediction (0.978; 95% CI, 0.941-1.000). Conclusions: The multibiomarker panel model yielded a highly accurate prediction of BSIs before their onset. Knowing patients' risk profile early will guide clinicians to take rapid preventive measures for limiting infections, promote antibiotic stewardship that may aid in alleviating the current antibiotic resistance crisis, shorten hospital length of stay and burden on health care resources, reduce health care costs, and significantly improve patients' outcomes. In addition, the biomarkers' identity and molecular functions may contribute to developing novel preventive interventions.

Design and Impact of a Novel Surgery-Specific Second Victim Peer Support Program.

BACKGROUND: Surgeons are prone to feelings of sadness, guilt, and anxiety when involved in major adverse events. We aimed to create and evaluate a second victim peer support program for surgeons and surgical trainees. STUDY DESIGN: The second victim peer support program was an intervention performed in the Department of Surgery at a tertiary care academic medical center. Surgical attendings and trainees participated as peer supporters or affected peers. In this article, we describe the design of the program and its 1-year impact, which was evaluated through the number of interventions attempted and realized and feedback received from all participants using an anonymous qualitative and quantitative survey. RESULTS: The program was established using the following 5 steps: creation of a conceptual framework, choice of peer supporters, training of peer supporters, multifaceted identification of major adverse events, and design of a systematic intervention plan. In 1 year, the program had 47 interventions distributed evenly between attendings and trainees; 19% of affected peers opted out of receiving support. Most participants expressed satisfaction with the program's confidentiality, the safe/trusting environment it provided, and the timeliness of the intervention (89%, 73%, and 83%, respectively); 81% suggested that the program had a positive impact on the department's "safety and support" culture and would recommend the program to a colleague. Several areas for improvement were identified, including the need to improve identification of events requiring outreach, and the desire for increased awareness of the program throughout the department. CONCLUSIONS: We successfully designed, implemented, and assessed the impact of the first surgery-specific peer support program in the US. Our 1-year experience suggests that the program is highly used and well received, albeit with opportunities for improvement.

Updating the Burn Center Referral Criteria: Results From the 2018 eDelphi Consensus Study.

Existing burn center referral criteria were developed several years ago, and subsequent innovations in burn care have occurred. Coupled with frequent errors in the estimation of extent of burn injury and depth by referring providers, patients are both over and under-triaged when the existing criteria are used to support patient care decisions. In the absence of compelling clinical trial data on appropriate burn patient triage, we convened a multidisciplinary panel of experts to execute an iterative eDelphi consensus process to facilitate a revision. The eDelphi process panel consisted of n = 61 burn stakeholders and experts and progressed through four rounds before reaching consensus on key clinical domains. The major findings are that 1) burn center consultation is strongly recommended for all patients with deep partial-thickness or deeper burns ≥ 10% TBSA burned, for full-thickness burns ≥ 5% TBSA burned, for children and older adults with specific dressing and medical needs, and for special burn circumstances including electrical, chemical, and radiation injuries; 2) smaller burns are ideally followed in burn center outpatient settings as soon as possible after injury, preferably without delays of a week or more; 3) frostbite, Stevens-Johnson syndrome/TENS, and necrotizing soft-tissue infection patients benefit from burn center treatment; and 4) telemedicine and technological solutions are of likely benefit in achieving this standard. Unlike the original criteria, the revised consensus-based guidelines create a framework promoting communication so that triage and treatment are specifically tailored to individual patient characteristics, injury severity, geography, and the capabilities of referring institutions.

The Relationship of Level of Education to Social Reintegration after Burn Injury: A LIBRE Study.

Social and emotional recovery from burn injury is a complex process impacted by both clinical and social factors. Because level of education (LOE) has been correlated to overall health, health outcomes, and life expectancy, we questioned whether LOE might be associated with successful social recovery after burn injury. The Life Impact Burn Recovery Evaluation (LIBRE) data set served as a novel tool to explore this question. The LIBRE project is a collaborative effort designed to provide a clinical yardstick for social reintegration among burn survivors. After institutional review board approval, 601 burn survivor respondents, aged 18 or over with >5% TBSA burn were surveyed and a six-scale, 126-item LIBRE Profile was derived from their responses. LOE was collapsed into four categories ranging from less than high school equivalency certificate to graduate degree. Impact of burn injury on subsequent LOE was examined by splitting the sample into those burned at age 30 years or less and those burned at greater than 30 years of age. Regression models were run to estimate associations between education and scale scores with adjustment for age at injury, sex, marital status, work status, TBSA, and time since burn. Regression models were run on the entire cohort and then stratified by age at burn injury (≤30 vs >30). Among all subjects, we found an association between LOE and social recovery as measured by LIBRE scale scores. This association was contributed entirely from the cohort burned at age 30 or less: for those burned at greater than age 30, there was no association between LOE and social recovery. Of particular interest, the distribution of LOE among those burned at ≤ 30 was very similar to LOE distribution in both millennials and in the U.S. population at large. LOE appears to be associated with social recovery for those burned at younger ages but not for those burned at over age 30. More importantly, burn injury during schooling may have no impact on a survivor's educational trajectory since distribution of LOE in our ≤30 cohort mirrors that of the general population. LOE and age at burn injury may provide a quick screen for survivors at risk of difficult social reintegration, allowing providers to target those at risk with additional peer support and counseling.

Western Trauma Association critical decisions in trauma: Preferred triage and initial management of the burned patient.

This is a recommended management algorithm from the Western Trauma Association addressing the management of victims of burn injury. Because there is a paucity of published prospective randomized clinical trials that have generated Class I data, these recommendations are based primarily on published retrospective studies, clinical guidelines, and the expert opinion of members of the Western Trauma Association in conjunction with partner members of the American Burn Association. The algorithm and accompanying comments represent one safe and sensible approach that can be followed at most trauma centers. We recognize that there may be patient or institutional factors that warrant deviation from the published algorithm. We would encourage institutions to use this document as a starting point toward a dialog with local burn centers to collaboratively create a patient-centered care experience for the victims of minor burn injuries arriving at local trauma centers.

Investigation into Possible Association of Oxandrolone and Heterotopic Ossification Following Burn Injury.

Oxandrolone, a testosterone analog, is used to counteract the catabolic effects of burn injury. Recent animal studies suggest a possible hormonal association with heterotopic ossification (HO) development postburn. This work examines oxandrolone administration and HO development by exploring historical clinical data bridging the introduction of oxandrolone into clinical practice. Additionally, we examine associations between oxandrolone administration and HO in a standardized mouse model of burn/trauma-related HO. Acutely burned adults admitted between 2000 and 2014, survived through discharge, and had a HO risk factor of 7 or higher were selected for analysis from a single burn center. Oxandrolone administration, clinical and demographic data, and elbow HO were recorded and were analyzed with logistic regression. Associations of oxandrolone with HO were examined in a mouse model. Mice were administered oxandrolone or vehicle control following burn/tenotomy to examine any potential effect of oxandrolone on HO and were analyzed by Student's t test. Subjects who received oxandrolone had a higher incidence of elbow HO than those that did not receive oxandrolone. However, when controlling for oxandrolone administration, oxandrolone duration, postburn day oxandrolone initiation, HO risk score category, age, sex, race, burn size, and year of injury, there was no significant difference between rates of elbow HO between the two populations. In agreement with the review, in the mouse model, while there was a trend toward the oxandrolone group developing a greater volume of HO, this did not reach statistical significance.

Teaching medical students about cost-effectiveness.

BACKGROUND: Rising and burdensome health care costs have driven interest in the practice of high-value care (HVC) and have inspired calls for increased HVC training across all levels of medical education, including among undergraduate medical students. CONTEXT: Classroom-based HVC curricula targeted to medical students have not been previously described in the medical literature. INNOVATION: We developed and evaluated a workshop comprising a lecture, a small-group exercise and a group discussion to instruct medical students on interpreting cost-effectiveness analyses (CEA), applying CEA to patient care and discussing the cost of care with patients. From January 2014 to September 2015 the workshop was administered to five cohorts, 120 students in total, in the internal medicine clerkships at two US medical schools. Pre- and post-intervention confidence in various domains was assessed with a Likert-type scale ranging from 1 to 4. The overall response rate was 87.9 per cent. The proportion of students reporting high confidence scores (3 or 4) rose significantly (p < 0.01) in each domain: from 16.2 to 76.9 per cent for calculating an incremental cost-effectiveness ratio (ICER); from 16.0 to 79.6 per cent for interpreting quality-adjusted life-years (QALYs); from 8.7 to 71.3 per cent for using CEA in patient management; and from 15.3 to 71.4 per cent for discussing costs with patients. Students rated the overall quality of the course as 3.82 out of 5. Rising and burdensome health care costs have driven interest in the practice of high-value care IMPLICATIONS: Our experience of developing, evaluating and refining an HVC course targeted at medical students taught us that such a course is needed, can be educational and can be well-received. Future research is needed to assess the effects of curricula on clinical practice.

Thermal injuries from exploding electronic cigarettes.

INTRODUCTION: There are an estimated 2.75 million electronic cigarette (EC) users in the United States. ECs have become the most commonly used nicotine-containing product in young adults ages 18-24 years. Thermal, blast, and missile injuries from EC explosions has grown rapidly in recent years. Burn surgeons must remain up to date regarding management and treatment of burn injuries related to EC device ignition. METHODS: An IRB approved retrospective review of all patients admitted to the Massachusetts General Hospital Burn Center from January 2015 to April 2017 was performed. Fourteen patients with injuries associated with EC use were identified. Patient demographics, injury location, size and degree of burn, treatments required, length of stay (LOS), time to 95% closure, associated complications and injuries, and the circumstances that led to the injury were identified. RESULTS: The mean age was 28.6±8.6 years with a range of 19-50 years (n=14). EC burns occurred in males 93% (13/14) of the time. The majority of EC explosions caused 2nd and 3rd degree burns (57%) within the same wound bed, followed by deep 2nd degree (29%), and superficial 2nd degree (14%). The average TBSA from EC burns was 4.7±2.4% with a range of 1-10%. The most common location of the device or battery at the time of the injury was a pant pocket 86% (12/14), followed by 7% hand (1/14) and 7% purse (1/14). Isolated lower extremity burns occurred in 43% (6/14) of patients, while lower extremity and hand burns occurred in 21% (3/14) of patients. Nine of 14 patients required an operating room encounter under general anesthesia. Eight of 14 patients required skin grafting for definitive wound closure. The mean hospital length of stay was 6.6±4.7 days with a range of 0-15 days. Time to 95% wound closure was 18.4±10.8 with a range of 8-40 days. CONCLUSION: Thermal and blast injuries associated with EC device failure tend to cause small TBSA burns that are deep 2nd and 3rd degree wounds. The most common location for EC device storage among males was the front pants pocket. EC device users should be made aware of the dangers associated with EC use and advised to carry EC devices away from their body in dedicated carrying cases without loose metallic items.

A rare case of severe third degree friction burns and large Morel-Lavallee lesion of the abdominal wall.

BACKGROUND: Morel-Lavallee lesions (MLLs) are rare internal degloving injuries typically caused by blunt traumatic injuries and most commonly occur around the hips and in association with pelvic or acetabular fractures. MLL is often overlooked in the setting of poly-trauma; therefore, clinicians must maintain a high degree of suspicion and be familiar with the management of such injuries, especially in obese poly-trauma patients. CASE PRESENTATION: We present a 30-year-old female pedestrian struck by a motor vehicle who sustained multiple long bone fractures, a mesenteric hematoma, and full-thickness abdominal skin friction burn which masked a significant underlying abdominal MLL. The internal degloving caused significant devascularization of the overlying soft tissue and skin which required surgical drainage of hematoma, abdominal wall reconstruction with tangential excision, allografting, negative pressure wound therapy, and ultimately autografting. CONCLUSION: MLL is a rare, often overlooked, internal degloving injury. Surgeons must maintain a high index of suspicion when dealing with third degree friction burns as they may mask underlying injuries such as MLL, and a delay in diagnosis can lead to increased morbidity.

Regional cost and experience, not size or hospital inclusion, helps predict ACO success.

The Medicare Shared Savings Program (MSSP) continues to expand and now includes 434 accountable care organizations (ACOs) serving more than 7 million beneficiaries. During 2014, 86 of these ACOs earned over $300 million in shared savings payments by promoting higher-quality patient care at a lower cost.Whether organizational characteristics, regional cost of care, or experience in the MSSP are associated with the ability to achieve shared savings remains uncertain.Using financial results from 2013 and 2014, we examined all 339 MSSP ACOs with a 2012, 2013, or 2014 start-date. We used a cross-sectional analysis to examine all ACOs and used a multivariate logistic model to predict probability of achieving shared savings.Experience, as measured by years in the MSSP program, was associated with success and the ability to earn shared savings varied regionally. This variation was strongly associated with differences in regional Medicare fee-for-service per capita costs: ACOs in high cost regions were more likely to earn savings. In the multivariate model, the number of ACO beneficiaries, inclusion of a hospital or involvement of an academic medical center, was not associated with likelihood of earning shared savings, after accounting for regional baseline cost variation.These results suggest ACOs are learning and improving from their experience. Additionally, the results highlight regional differences in ACO success and the strong association with variation in regional per capita costs, which can inform CMS policy to help promote ACO success nationwide.