Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations.

BACKGROUND: Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations. OBJECTIVE: Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). DESIGN: Cross-sectional study using ordinary least squares regression controlling for patient and community factors. PARTICIPANTS: Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid. MAIN MEASURES: Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022. KEY RESULTS: Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001). CONCLUSIONS: Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.

Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries.

Importance: Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality. Objective: To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery. Design, Setting, and Participants: Cross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022. Exposures: Physician practice participation in the bundled payment program. Main Outcomes and Measures: The primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions). Results: The final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]). Conclusions and Relevance: In this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.

The Association between Bundled Payment Participation and Changes in Medical Episode Outcomes among High-Risk Patients.

Background: Bundled payments for medical conditions are associated with stable quality and savings through shorter skilled nursing facility (SNF) length of stay. However, effects among clinically higher-risk patients remain unknown. Objective: To evaluate whether the association between participation in bundled payments for medical conditions and episode outcomes differed for clinically high-risk versus other patients. Design: Retrospective difference-in-differences analysis; Participants: 471,421 Medicare patients hospitalized at bundled payment and propensity-matched non-participating hospitals. Exposures were 5 measures of clinically high-risk groups: advanced age (>85 years old), high case-mix, disabled, frail, and prior institutional post-acute care provider utilization. Main Measures: Primary outcomes were SNF length of stay and 90-day unplanned readmissions. Secondary outcomes included quality, utilization, and spending measures. Key Results: SNF length of stay was differentially lower among frail patients (aDID −0.4 days versus non-frail patients, 95% CI −0.8 to −0.1 days), patients with advanced age (aDID −0.8 days versus younger patients, 95% CI −1.2 to −0.3 days), and those with prior institutional post-acute care provider utilization (aDID −1.1 days versus patients without prior utilization, 95% CI −1.6 to −0.6 days), compared to non-frail, younger, and patients without prior utilization, respectively. BPCI participation was also associated with differentially greater SNF LOS among disabled patients (aDID 0.8 days versus non-disabled patients, 95% CI 0.4 to 1.2 days, p < 0.001). Bundled payment participation was not associated with differential changes in readmissions in any high-risk group but was associated with changes in secondary outcomes for some groups. Conclusions: Changes under medical bundles affected, but did not indiscriminately apply to, high-risk patient groups.

Performance of Physician Groups and Hospitals Participating in Bundled Payments Among Medicare Beneficiaries.

Importance: Hospital participation in bundled payment initiatives has been associated with financial savings and stable quality of care. However, how physician group practices (PGPs) perform in bundled payments compared with hospitals remains unknown. Objectives: To evaluate the association of PGP participation in the Bundled Payments for Care Improvement (BPCI) initiative with episode outcomes and to compare these with outcomes for participating hospitals. Design, Settings, and Participants: This cohort study with a difference-in-differences analysis used 2011 to 2018 Medicare claims data to compare the association of BPCI participation with episode outcomes for PGPs vs hospitals providing medical and surgical care to Medicare beneficiaries. Data analyses were conducted from January 1, 2020, to May 31, 2022. Exposures: Hospitalization for any of the 10 highest-volume episodes (5 medical and 5 surgical) included in the BPCI initiative for Medicare patients of participating PGPs and hospitals. Main Outcomes and Measures: The primary outcome was 90-day total episode spending. Secondary outcomes were 90-day readmissions and mortality. Results: The total sample comprised data from 1 288 781 Medicare beneficiaries, of whom 696 710 (mean [SD] age, 76.2 [10.8] years; 432 429 [59.7%] women; 619 655 [85.5%] White individuals) received care through 379 BPCI-participating hospitals and 1441 propensity-matched non-BPCI-participating hospitals, and 592 071 (mean [SD] age, 75.4 [10.9] years; 527 574 [86.6%] women; 360 835 [59.3%] White individuals) received care from 6405 physicians in BPCI-participating PGPs and 24 758 propensity-matched physicians in non-BPCI-participating PGPs. For PGPs, BPCI participation was associated with greater reductions in episode spending for surgical (difference, -$1368; 95% CI, -$1648 to -$1088) but not for medical episodes (difference, -$101; 95% CI, -$410 to $206). Hospital participation in BPCI was associated with greater reductions in episode spending for both surgical (-$1010; 95% CI, -$1345 to -$675) and medical (-$763; 95% CI, -$1139 to -$386) episodes. Conclusions and Relevance: This cohort study and difference-in-differences analysis of PGPs and hospital participation in BPCI found that bundled payments were associated with cost savings for surgical episodes for PGPs, and savings for both surgical and medical episodes for hospitals. Policy makers should consider the comparative performance of participant types when designing and evaluating bundled payment models.

The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments.

Hospitals have demonstrated the benefits of both voluntary and mandatory bundled payments for joint replacement surgery. However, given generalizability and disparities concerns, it is critical to understand the availability of care through bundled payments to historically marginalized groups, such as racial and ethnic minorities and individuals with lower socioeconomic status (SES). This cross-sectional analysis of 3880 US communities evaluated the relationship between the proportion of Black and Hispanic individuals (minority share) or Medicare/Medicaid dual-eligible individuals (low SES share) and community-level participation in Bundled Payments for Care Improvement initiative (BPCI) (being a BPCI community) and Comprehensive Care for Joint Replacement (CJR) model (being a CJR community). An increase from the lowest to highest quartile of minority share was not associated with differences in the probability of being a BPCI community (3.5 percentage point [pp] difference, 95% confidence interval [CI] -1.2% to 8.3%, P = 0.15), but was associated with a 16.1 pp higher probability of being a CJR community (95% CI 10.3% to 22.0%, P < 0.0001). An increase from the lowest to highest quartile of low SES share was associated with a 6.0 pp lower probability of being a BPCI community (95% CI -10.9% to -1.2%, P = 0.02) and 19.0 pp lower probability of being a CJR community (95% CI -24.9% to -13.0%, P < 0.0001). These findings highlight that the greater the proportion of lower SES individuals in a community, the lower the likelihood that its hospitals participated in either voluntary or mandatory bundled payments. Policymakers should consider community socioeconomic characteristics when designing participation mechanisms for future bundled payment programs.

The Effect of Hospital Safety Net Status on the Association Between Bundled Payment Participation and Changes in Medical Episode Outcomes.

BACKGROUND: Under Medicare's Bundled Payments for Care Improvement (BPCI) program, hospitals have maintained quality and achieved savings for medical conditions. However, safety net hospitals may perform differently owing to financial constraints and organizational challenges. OBJECTIVE: To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes. DESIGN, SETTING, AND PARTICIPANTS: This observational difference-in-differences analysis was conducted in safety net and non-safety net hospitals participating in BPCI for medical episodes (BPCI hospitals) using data from 2011-2016 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease. EXPOSURE(S): Hospital BPCI participation and safety net status. MAIN OUTCOME(S) AND MEASURE(S): The primary outcome was postdischarge spending. Secondary outcomes included quality and post-acute care utilization measures. RESULTS: Our sample consisted of 803 safety net and 2263 non-safety net hospitals. Safety net hospitals were larger and located in areas with more low-income individuals than non-safety net hospitals. Among BPCI hospitals, safety net status was not associated with differential postdischarge spending (adjusted difference-in-differences [aDID], $40; 95% CI, -$254 to $335; P = .79) or quality (mortality, readmissions). However, BPCI safety net hospitals had differentially greater discharge to institutional post-acute care (aDID, 1.06 percentage points; 95% CI, 0.37-1.76; P = .003) and lower discharge home with home health (aDID, -1.15 percentage points; 95% CI, -1.73 to -0.58; P < .001) than BPCI non-safety net hospitals. CONCLUSIONS: Under medical condition bundles, safety net hospitals perform differently from other hospitals in terms of post-acute care utilization, but not spending. Policymakers could support safety net hospitals and consider safety net status when evaluating bundled payment programs.

Urinary and salivary endocrine measurements to complement Tanner staging in studies of pubertal development.

BACKGROUND: Many studies investigating pubertal development use Tanner staging to assess maturation. Endocrine markers in urine and saliva may provide an objective, sensitive, and non-invasive method for assessing development. OBJECTIVE: Our objective was to examine whether changes in endocrine levels can indicate the onset of pubertal development prior to changes in self-rated Tanner stage. METHODS: Thirty-five girls and 42 boys aged 7 to 15 years were enrolled in the Growth and Puberty (GAP) study, a longitudinal pilot study conducted from 2007-2009 involving children of women enrolled in the Agricultural Health Study (AHS) in Iowa. We collected saliva and urine samples and assessed pubertal development by self-rated Tanner staging (pubic hair, breast development (girls), genital development (boys)) at three visits over six months. We measured dehydroepiandrosterone (DHEA) in saliva and creatinine-adjusted luteinizing hormone (LH), testosterone, follicle stimulating hormone (FSH), estrone 3-glucuronide (E13G) and pregnanediol 3-glucuronide (Pd3G) concentrations in first morning urine. We evaluated the relationships over time between Tanner stage and each biomarker using repeated measures analysis. RESULTS: Among girls still reporting Tanner breast stage 1 at the final visit, FSH levels increased over the 6-month follow-up period and were no longer lower than higher stage girls at the end of follow-up. We observed a similar pattern for testosterone in boys. By visit 3, boys still reporting Tanner genital stage 1 or pubic hair stage 1 had attained DHEA levels that were comparable to those among boys reporting Tanner stages 2 or 3. CONCLUSIONS: Increasing concentrations of FSH in girls and DHEA and testosterone in boys over a 6-month period revealed the start of the pubertal process prior to changes in self-rated Tanner stage. Repeated, non-invasive endocrine measures may complement the more subjective assessment of physical markers in studies determining pubertal onset.

Association of Patient Outcomes With Bundled Payments Among Hospitalized Patients Attributed to Accountable Care Organizations.

Importance: It is unknown how outcomes are affected when patients receive care under bundled payment and accountable care organization (ACO) programs simultaneously. Objective: To evaluate whether outcomes in the Medicare Bundled Payments for Care Improvement (BPCI) program differed depending on whether patients were attributed to ACOs in the Medicare Shared Savings Program. Design Setting and Participants: This cohort study was conducted using Medicare claims data from January 1, 2011, to September 30, 2016, and difference-in-differences analysis to compare episode outcomes for patients admitted to BPCI vs non-BPCI hospitals. Outcomes were stratified for patients who were and were not attributed to an ACO. Participants included Medicare fee-for-service beneficiaries receiving care for medical and surgical episodes at US hospitals. Data were analyzed between October 1, 2018, and June 10, 2021. Exposures: Hospitalization for any of the 48 episodes (24 medical, 24 surgical) included in the BPCI at US hospitals participating in the BPCI for those episodes. Main Outcomes and Measures: The primary outcome was change in 90-day postdischarge institutional spending, and secondary outcomes included changes in quality and utilization. Results: A total of 7 108 146 beneficiaries (mean [SD] age, 76.9 [12.2] years; 4 101 081 women [58%]) received care for medical episodes, and 3 675 962 beneficiaries (mean [SD] age, 74.8 [10.1] years; 2 074 921 women [56%]) received care for surgical episodes. Compared with patients who were not attributed to ACOs, the association between bundled payments and changes in postdischarge institutional spending was larger among patients attributed to ACOs (-$323 difference; 95% CI, -$607 to -$39; P = .03) for medical episodes, but not surgical episodes. Attribution to an ACO also increased the strength of the association between bundled payments and changes in 90-day readmissions for both medical episodes (-0.98 percentage point difference; 95% CI, -1.55 to -0.41; P = .001) and surgical episodes (-0.84 percentage point difference; 95% CI, -1.32 to -0.35; P = .001). Conclusions and Relevance: In this cohort study, compared with inclusion in bundled payments alone, simultaneous inclusion in both ACOs and bundled payment programs was associated with lower institutional postacute care spending and readmissions for medical episodes and lower readmissions but not spending for surgical episodes. Receiving care under models such as ACOs may improve episode outcomes under bundled payments.

Spillover Effects of Medicare's Voluntary Bundled Payments for Joint Replacement Surgery to Patients Insured by Commercial Health Plans.

BACKGROUND: Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service beneficiaries. OBJECTIVE: To examine the association between hospital participation in BPCI and LEJR outcomes for patients with commercial insurance or Medicare Advantage (MA). DESIGN: Quasi-experimental study using Health Care Cost Institute claims from 2011 to 2016. SETTING: LEJR at 281 BPCI hospitals and 562 non-BPCI hospitals. PATIENTS: 184 922 patients with MA or commercial insurance. MEASUREMENTS: Differential changes in LEJR outcomes at BPCI hospitals versus at non-BPCI hospitals matched on propensity score were evaluated using a difference-in-differences (DID) method. Secondary analyses evaluated associations by patient MA status and hospital characteristics. Primary outcomes were changes in 90-day total spending on LEJR episodes and 90-day readmissions; secondary outcomes were postacute spending and discharge to postacute care providers. RESULTS: Average episode spending decreased more at BPCI versus non-BPCI hospitals (change, -2.2% [95% CI, -3.6% to -0.71%]; P = 0.004), but differences in changes in 90-day readmissions were not significant (adjusted DID, -0.47 percentage point [CI, -1.0 to 0.06 percentage point]; P = 0.084). Participation in BPCI was also associated with differences in decreases in postacute spending and discharge to institutional postacute care providers. Decreases in episode spending were larger for hospitals with high baseline spending but did not vary by MA status. LIMITATION: Nonrandomized studies are subject to residual confounding and selection. CONCLUSION: Participation in BPCI was associated with modest spillovers in episode savings. Bundled payments may prompt hospitals to implement broad care redesign that produces benefits regardless of insurance coverage. PRIMARY FUNDING SOURCE: Leonard Davis Institute of Health Economics at the University of Pennsylvania.

Overlap Between Medicare's Comprehensive Care for Joint Replacement Program and Accountable Care Organizations.

BACKGROUND: Overlap between Medicare's Comprehensive Care for Joint Replacement (CJR) model and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels. METHODS: We conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post-Acute Care Transformation file. On the beneficiary level, we conducted 2 comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap). RESULTS: We studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be of nonprofit and less likely to be of safety net. CONCLUSION: CJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.

Spillover effects of mandatory hip and knee replacement surgery bundles in medicare.

BACKGROUND: Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could "spill over" to individuals insured through private health plans. Definitive evidence of spillovers remains lacking. OBJECTIVE: To evaluate the association between CJR participation and changes in outcomes among privately insured individuals. DESIGN, SETTING, PARTICIPANTS: We used 2013-2017 Health Care Cost Institute claims for 418,016 privately insured individuals undergoing joint replacement in 75 CJR and 121 Non-CJR markets. Multivariable generalized linear models with hospital and market random effects and time fixed effects were used to analyze the association between CJR participation and changes in outcomes. MAIN OUTCOMES AND MEASURES: Total episode spending, discharge to institutional post-acute care, and quality (e.g., surgical complications, readmissions). RESULTS: Patients in CJR and Non-CJR markets did not differ in total episode spending (difference of -$157, 95% CI -$1043 to $728, p = 0.73) or discharge to institutional post-acute care (difference of -1.1%, 95% CI -3.2%-1.0%, p = 0.31). Similarly, patients in the two groups did not differ in quality or other utilization outcomes. Findings were generally similar in stratified and sensitivity analyses. CONCLUSIONS: There was a lack of evidence of cost or utilization spillovers from CJR to privately insured individuals. There may be limits in the ability of certain value-based payment reforms to drive broad changes in care delivery and patient outcomes.

Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study.

OBJECTIVE: To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use. DESIGN: Quasi-experimental difference-in-differences analysis. SETTING: US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals. PARTICIPANTS: 238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals. MAIN OUTCOME MEASURES: Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply. RESULTS: In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points). CONCLUSIONS: In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

Spending And Quality After Three Years Of Medicare's Voluntary Bundled Payment For Joint Replacement Surgery.

Medicare has reinforced its commitment to voluntary bundled payment by building upon the Bundled Payments for Care Improvement (BPCI) initiative via an ongoing successor program, the BPCI Advanced Model. Although lower extremity joint replacement (LEJR) is the highest-volume episode in both BPCI and BPCI Advanced, there is a paucity of independent evidence about its long-term impact on outcomes and about whether improvements vary by timing of participation or arise from patient selection rather than changes in clinical practice. We found that over three years, compared to no participation, participation in BPCI was associated with a 1.6 percent differential decrease in average LEJR episode spending with no differential changes in quality, driven by early participants. Patient selection accounted for 27 percent of episode savings. Our findings have important policy implications in view of BPCI Advanced and its two participation waves.

Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations.

Importance: An increasing number of hospitals have participated in Medicare's bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes given the prevalence of LEJR among patients receiving care at ACO participant organizations and potential overlap in care redesign strategies adopted under the 2 payment models. Objective: To examine whether simultaneous participation in a Medicare Shared Savings Program (MSSP) ACO affects the association between hospitals' participation in LEJR episodes under the Bundled Payments for Care Improvement (BPCI) initiative and patient outcomes compared with participation in the BPCI initiative alone. Design, Setting, and Participants: This cohort study, conducted from January 1 to May 31, 2019, used 2011 to 2016 Medicare claims data and incorporated an instrumental variable with a difference-in-differences method among 483 008 fee-for-service Medicare beneficiaries undergoing LEJR surgery at 212 bundled payment participant hospitals, 105 coparticipant hospitals, and 1413 nonparticipant hospitals in the United States. Exposures: Hospital participation in both the BPCI initiative and the MSSP (coparticipants), BPCI only (bundled payment participants), or neither (nonparticipants). Main Outcomes and Measures: Changes in clinical outcomes and mean LEJR episode spending. Results: A total of 483 008 patients (mean [SD] age, 73.0 [8.4] years; 308 173 [63.8%] female) were included in the study. No differential changes were found in patient and hospital characteristics across participation groups. In adjusted analysis, coparticipants had 1.5% (95% CI, 0.7%-2.2%; P < .001) more unplanned readmissions than did bundled payment participants. Compared with bundled payment participants, coparticipants also had differentially greater decreases in hospital length of stay (adjusted difference-in-differences value, -5.3%; 95% CI, -7.1% to -3.5%; P < .001) and home health care use (adjusted difference-in-differences value, -3.4%; 95% CI, -4.5% to -2.3%; P < .001) and greater increases in postdischarge outpatient follow-up (adjusted difference-in-differences value, 2.1%; 95% CI, 0.9%-3.3%; P < .001). Coparticipants and bundled payment participants did not have differential changes in episode spending (adjusted difference-in-differences value, 0.4%; 95% CI, -0.7% to 1.6%; P = .46), although both groups had more decreased spending compared with nonparticipants. Conclusions and Relevance: Among bundled payment participants, coparticipation in ACOs was not associated with LEJR episode savings but was associated with differential changes in postacute care use patterns and unplanned readmissions. These findings support the longer-term benefits of LEJR bundles and suggest that coparticipants may adopt care redesign strategies that differ from hospitals with bundled payments only.

National Representativeness Of Hospitals And Markets In Medicare's Mandatory Bundled Payment Program.

In 2016 Medicare implemented its first mandatory alternative payment model, the Comprehensive Care for Joint Replacement (CJR) program, in which the agency pays clinicians and hospitals a fixed amount for services provided in hip and knee replacement surgery episodes. Medicare made CJR mandatory, rather than voluntary, to produce generalizable evidence on what results Medicare might expect if it scaled bundled payment up nationally. However, it is unknown how markets and hospitals in CJR compare to others nationwide, particularly with respect to baseline quality and spending performance and the structural hospital characteristics associated with early savings in CJR. Using data from Medicare, the American Hospital Association, and the Health Resources and Services Administration, we found differences in structural market and hospital characteristics but largely similar baseline hospital episode quality and spending. Our findings suggest that despite heterogeneity in hospital characteristics associated with early savings in CJR, Medicare might nonetheless reasonably expect similar results by scaling CJR up to additional urban markets and increasing total program coverage to areas in which 71 percent of its beneficiaries reside. In contrast, different policy designs may be needed to extend market-level programs to other regions or enable different hospital types to achieve savings from bundled payment reimbursement.

Meta-analyses on prevalence of selected Parkinson's nonmotor symptoms before and after diagnosis.

BACKGROUND: Nonmotor symptoms are common among patients with Parkinson's disease (PD) and some may precede disease diagnosis. METHODS: We conducted a meta-analysis on the prevalence of selected nonmotor symptoms before and after PD diagnosis, using random-effect models. We searched PubMed (1965 through October/November 2012) for the following symptoms: hyposmia, constipation, rapid eye movement sleep behavior disorder, excessive daytime sleepiness, depression, and anxiety. Eligible studies were publications in English with original data on one or more of these symptoms. RESULTS: The search generated 2,373 non-duplicated publications and 332 met the inclusion criteria, mostly (n = 320) on symptoms after PD diagnosis. For all symptoms, the prevalence was substantially higher in PD cases than in controls, each affecting over a third of the patients. Hyposmia was the most prevalent (75.5% in cases vs. 19.1% in controls), followed by constipation (50% vs. 17.7%), anxiety (39.9% vs. 19.1%), rapid eye movement sleep behavior disorder (37.0% vs. 7.0%), depression (36.6% vs. 14.9%), and excessive daytime sleepiness (33.9% vs. 10.5%). We observed substantial heterogeneities across studies and meta-regression analyses suggested that several factors might have contributed to this. However, the prevalence estimates were fairly robust in several sensitivity analyses. Only 20 studies had data on any symptoms prior to PD diagnosis, but still the analyses revealed higher prevalence in future PD cases than in controls. CONCLUSION: These symptoms are common among PD patients both before and after diagnosis. Further studies are needed to understand the natural history of nonmotor symptoms in PD and their etiological and clinical implications.

Uterine leiomyomata associated with self-reported stress urinary incontinence.

AIMS: To investigate the association between the presence and characteristics of uterine leiomyomata (UL) and self-reported stress urinary incontinence (SUI). METHODS: The study included 836 premenopausal participants (474 African American and 362 Caucasian) in the National Institute of Environmental Health Sciences (NIEHS) Uterine Fibroid Study. UL were characterized at baseline with ultrasound screening, and SUI was assessed at follow-up (after 4 years, on average). Linear risk models were used to estimate adjusted prevalence differences (aPD) and 95% confidence intervals (CI), controlling for age, ethnicity, body mass index (BMI), and number of deliveries. RESULTS: Compared with women without UL, SUI prevalence was higher among women with any UL (aPD = 7.4%, 95% CI 0.4-14.3) and women with UL 2-4 cm (aPD = 9.6%, 95% CI 1.3-17.9). Marginally significant results were found for the presence of UL > or =4 cm and anterior UL > or =2 cm. CONCLUSIONS: The observed 7% increase in prevalence of this common condition for women with UL is of clinical importance. Further research is needed before concluding that treatment for larger UL might enhance SUI treatment in some women.

Association of race, age and body mass index with gross pathology of uterine fibroids.

OBJECTIVE: To determine the associations of race, age and body mass index (BMI) with the gross pathology parameters of uterine leiomyomas in premenopausal women undergoing hysterectomy or myomectomy. STUDY DESIGN: Participants (N = 107) were recruited from surgical rosters of the George Washington University (GWU) Medical Center Gynecology Department as part of the National Institute of Environmental Health Sciences Fibroid Study. Tumor data and patient demographics were obtained from clinical reports, pathology forms and interviews. RESULTS: Surgical cases consisted of 78% African Americans, 13% Caucasians and 9% others (non-African American, non-Caucasian or race unknown). This proportion of African Americans was significantly higher than the distribution of GWU health plan participants. Fibroids were localized predominantly within the intramural region. Subserosal tumors were more common in patients with more than 9 tumors. African Americans had the highest mean BMI and mean myomatous uterine weight. CONCLUSION: African Americans were the disproportionate majority coming to surgery for fibroids. The average BMI and uterine weight were greater in African Americans than in Caucasians, although these differences were marginal. Race did not influence the size, location or number of fibroids in these surgical cases. Subserosal tumors were more common in patients with more than 9 tumors.