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2.
J Stroke Cerebrovasc Dis ; 29(12): 105399, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33254370

RESUMO

BACKGROUND: Limited real-world data are available on outcomes following non-cardioembolic minor ischemic stroke (IS) or high-risk transient ischemic attack (TIA), particularly in the United States (US). We examined outcomes and Medicare payments following any severity IS or TIA as well as the subgroup with minor IS or high-risk TIA. METHODS: Medicare beneficiaries >65 years were identified using US nationwide Get with the Guidelines (GWTG)-Stroke Registry linked to Medicare claims data. The cohort consisted of patients enrolled in Medicare fee-for-service plan, hospitalized with non-cardioembolic IS or TIA between 2011 and 2014, segmenting a subgroup with minor IS (National Institute of Health Stroke Scale [NIHSS] ≤5) or high-risk TIA (ABCD2-score ≥6) compatible with the THALES clinical trial population. Outcomes included functional status at discharge, clinical outcomes (all-cause mortality, ischemic stroke, and hemorrhagic stroke, individually and as a composite), hospitalizations, and population average inpatient Medicare payments following non-cardioembolic IS or TIA. RESULTS: The THALES-compatible cohort included 62,518 patients from 1471 hospitals. At discharge, 37.0% were unable to ambulate without assistance, and 96.2% were prescribed antiplatelet therapy. Cumulative incidences at 30 days, 90 days, and 1 year for the composite outcome were 3.7%, 7.6%, and 17.2% and 2.4%, 4.0%, and 7.3% for subsequent stroke. The mean Medicare payment for the index hospitalization was $7951. The cumulative all-cause inpatient Medicare spending per patient (with or without any subsequent admission) at 30 days and 1 year from discharge was $1451 and $8105, respectively. CONCLUSIONS: The burden of illness for minor IS/high-risk TIA patients indicates an important unmet need. Improved therapeutic options may offer a significant impact on both patient outcomes and Medicare spending.

3.
Am J Manag Care ; 26(12): 534-540, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33315328

RESUMO

OBJECTIVES: Since 2019, the Medicare Shared Savings Program (MSSP) has allowed accountable care organizations (ACOs) to choose either retrospectively or prospectively attributed ACO populations. To understand how ACOs' choice of attribution method affects incentives for care among seriously ill Medicare beneficiaries, this study compares beneficiary characteristics and Medicare per capita expenditures between prospective and retrospective ACO populations. STUDY DESIGN: This retrospective, cross-sectional analysis describes survival, patient characteristics, and Medicare spending for Medicare fee-for-service beneficiaries identified with serious illness (n = 1,600,629) using 100% Medicare Master Beneficiary Summary and MSSP beneficiary files (2014-2016). METHODS: We used generalized linear models with ACO and year fixed effects to estimate the average within-ACO difference between potential retrospective and prospective ACO populations. RESULTS: Dying in the first 90 days of the performance year was associated with reduced odds of retrospective ACO attribution (odds ratio [OR], 0.24; 95% CI, 0.24-0.25) relative to beneficiaries surviving 270 days or longer. Similarly, hospice use was associated with reduced odds of retrospective assignment (OR, 0.80; 95% CI, 0.79-0.80). Among ACOs that did not achieve shared savings, average per capita Medicare expenditures (after truncation) were $2459 (95% CI, $2192-$2725) higher for prospective vs retrospective ACO populations. The difference was $834 (95% CI, $402-$1266) greater per capita among ACOs that achieved shared savings. CONCLUSIONS: The difference in survival and spending for ACO populations captured by prospective vs retrospective attribution methods means that ACOs may need to employ different care management strategies to improve performance depending on their attribution method.

4.
J Gen Intern Med ; 2020 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-33169328

RESUMO

In the original version of this paper, an author was misidentified. The corrected author listing appears here, and has been updated in the online version.

5.
J Gen Intern Med ; 35(12): 3627-3634, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33021717

RESUMO

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) infected over 5 million United States (US) residents resulting in more than 180,000 deaths by August 2020. To mitigate transmission, most states ordered shelter-in-place orders in March and reopening strategies varied. OBJECTIVE: To estimate excess COVID-19 cases and deaths after reopening compared with trends prior to reopening for two groups of states: (1) states with an evidence-based reopening strategy, defined as reopening indoor dining after implementing a statewide mask mandate, and (2) states reopening indoor dining rooms before implementing a statewide mask mandate. DESIGN: Interrupted time series quasi-experimental study design applied to publicly available secondary data. PARTICIPANTS: Fifty United States and the District of Columbia. INTERVENTIONS: Reopening indoor dining rooms before or after implementing a statewide mask mandate. MAIN MEASURES: Outcomes included daily cumulative COVID-19 cases and deaths for each state. KEY RESULTS: On average, the number of excess cases per 100,000 residents in states reopening without masks is ten times the number in states reopening with masks after 8 weeks (643.1 cases; 95% confidence interval (CI) = 406.9, 879.2 and 62.9 cases; CI = 12.6, 113.1, respectively). Excess cases after 6 weeks could have been reduced by 90% from 576,371 to 63,062 and excess deaths reduced by 80% from 22,851 to 4858 had states implemented mask mandates prior to reopening. Over 50,000 excess deaths were prevented within 6 weeks in 13 states that implemented mask mandates prior to reopening. CONCLUSIONS: Additional mitigation measures such as mask use counteract the potential growth in COVID-19 cases and deaths due to reopening businesses. This study contributes to the growing evidence that mask usage is essential for mitigating community transmission of COVID-19. States should delay further reopening until mask mandates are fully implemented, and enforcement by local businesses will be critical for preventing potential future closures.

6.
Artigo em Inglês | MEDLINE | ID: mdl-32947017

RESUMO

CONTEXT: Palliative care (PC) programs are typically evaluated using observational data, raising concerns about selection bias. OBJECTIVES: To quantify selection bias because of observed and unobserved characteristics in a PC demonstration program. METHODS: Program administrative data and 100% Medicare claims data in two states and a 20% sample in eight states (2013-2017). The sample included 2983 Medicare fee-for-service beneficiaries aged 65+ participating in the PC program and three matched cohorts: regional; two states; and eight states. Confounding because of observed factors was measured by comparing patient baseline characteristics. Confounding because of unobserved factors was measured by comparing days of follow-up and six-month and one-year mortality rates. RESULTS: After matching, evidence for observed confounding included differences in observable baseline characteristics, including race, morbidity, and utilization. Evidence for unobserved confounding included significantly longer mean follow-up in the regional, two-state, and eight-state comparison cohorts, with 207 (P < 0.001), 192 (P < 0.001), and 187 (P < 0.001) days, respectively, compared with the 162 days for the PC cohort. The PC cohort had higher six-month and one-year mortality rates of 53.5% and 64.5% compared with 43.5% and 48.0% in the regional comparison, 53.4% and 57.4% in the two-state comparison, and 55.0% and 59.0% in the eight-state comparison. CONCLUSION: This case study demonstrates that selection of comparison groups impacts the magnitude of measured and unmeasured confounding, which may change effect estimates. The substantial impact of confounding on effect estimates in this study raises concerns about the evaluation of novel serious illness care models in the absence of randomization. We present key lessons learned for improving future evaluations of PC using observational study designs.

7.
Artigo em Inglês | MEDLINE | ID: mdl-32858165

RESUMO

CONTEXT: Hospice facilities are increasingly preferred as a location of death, but little is known about the characteristics of patients who die in these facilities in the U.S. OBJECTIVES: We sought to examine the trends and factors associated with death in a hospice facility. METHODS: Retrospective cross-sectional study using mortality data for years 2003-2017 for deaths attributed to natural causes in the U.S. RESULTS: The proportion of natural deaths occurring in hospice facilities increased from 0.2% in 2003 to 8.3% in 2017, resulting in nearly 1.7 million deaths during this time frame. Females had increased odds of hospice facility deaths (odds ratio [OR] = 1.04; 95% CI = 1.04, 1.05). Nonwhite race was associated with lower odds of hospice facility death (black [OR = 0.915; 95% CI = 0.890, 0.940]; Native American [OR = 0.559; 95% CI = 0.515, 0.607]; and Asian [OR = 0.655; 95% CI = 0.601, 0.713]). Being married was associated with hospice facility death (OR = 1.06; 95% CI = 1.04, 1.07). Older age was associated with increased odds of hospice facility death (85 and older [OR = 1.40; 95% CI = 1.39, 1.41]). Having at least some college education was associated with increased odds of hospice facility death (OR = 1.13; 95% CI = 1.11, 1.15). Decedents from cardiovascular disease had the lowest odds of hospice facility death (OR = 0.278; 95% CI = 0.274, 0.282). CONCLUSION: Hospice facility deaths increased among all patient groups; however, striking differences exist by age, sex, race, marital status, education level, cause of death, and geography. Factors underlying these disparities should be examined.

8.
J Rural Health ; 36(4): 584-590, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32603030

RESUMO

PURPOSE: During the COVID-19 epidemic, it is critical to understand how the need for hospital care in rural areas aligns with the capacity across states. METHODS: We analyzed data from the 2018 Behavioral Risk Factor Surveillance System to estimate the number of adults who have an elevated risk of serious illness if they are infected with coronavirus in metropolitan, micropolitan, and rural areas for each state. Study data included 430,949 survey responses representing over 255.2 million noninstitutionalized US adults. For data on hospital beds, aggregate survey data were linked to data from the 2017 Area Health Resource Files by state and metropolitan status. FINDINGS: About 50% of rural residents are at high risk for hospitalization and serious illness if they are infected with COVID-19, compared to 46.9% and 40.0% in micropolitan and metropolitan areas, respectively. In 19 states, more than 50% of rural populations are at high risk for serious illness if infected. Rural residents will generate an estimated 10% more hospitalizations for COVID-19 per capita than urban residents given equal infection rates. CONCLUSION: More than half of rural residents are at increased risk of hospitalization and death if infected with COVID-19. Experts expect COVID-19 burden to outpace hospital capacity across the country, and rural areas are no exception. Policy makers need to consider supply chain modifications, regulatory changes, and financial assistance policies to assist rural communities in caring for people affected by COVID-19.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Serviços de Saúde Rural/estatística & dados numéricos , População Rural/estatística & dados numéricos , Índice de Gravidade de Doença , Adulto , Feminino , Hospitais Rurais/organização & administração , Humanos , Masculino , Pandemias , Estados Unidos
9.
J Palliat Med ; 23(4): 568-572, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32176563

RESUMO

The field of palliative care (PC) has spent the past decade demonstrating that it improves outcomes for patients, clinicians, and health systems. Forward-thinking organizations preparing for a reimbursement system rooted in value have built robust inpatient PC programs and are rapidly moving toward the outpatient and community settings as well. As PC programs get larger and are increasingly tasked with leading a wide variety of diverse initiatives, population health principles can help to focus programs on high-value activities. This article, written by population health researchers and PC clinicians, seeks to provide PC teams nationally with a variety of population health strategies and tools to guide PC delivery throughout the health system and beyond.

10.
J Am Geriatr Soc ; 68(2): 250-255, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31609481

RESUMO

OBJECTIVES: To assess trends and factors associated with place of death among individuals with Alzheimer's disease-related dementias (ADRD). DESIGN: Cross-sectional analysis. SETTING: Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research, 2003-2017. PARTICIPANTS: Natural deaths occurring between 2003 and 2017 for which ADRD was determined to be the underlying cause. MEASUREMENTS: Place of death was categorized as hospital, home, nursing facility, hospice facility, and other. Aggregate data included age, race, Hispanic ethnicity, sex, urbanization, and census division. Individual-level predictors included age, race, Hispanic ethnicity, sex, marital status, and education. RESULTS: From 2003 to 2017, nursing facility and hospital deaths declined from 65.7% and 12.7% to 55.0% and 8.0% while home and hospice facility deaths increased from 13.6% and .2% to 21.9% and 6.2%, respectively. Odds of hospital and hospice facility deaths declined with age while odds of nursing facility deaths increased with age. Male sex was associated with higher odds of hospital or hospice facility death and lower odds of home or nursing facility death. Nonwhite race, Hispanic ethnicity, and being married were associated with increased odds of hospital or home death and reduced odds of nursing facility death. More education was associated with higher odds of home or in a hospice facility death and reduced odds of death in a nursing facility or hospital. Significant disparities in place of death by urban-rural status were also noted. CONCLUSION: As ADRD deaths at home increase, the need for caregiver support and home-based palliative care may become more critical. Further research should examine the care preferences and experiences of ADRD patients and caregivers, the financial impact of home death on families and insurers, and explore factors that may contribute to differences in actual and preferred place of death. J Am Geriatr Soc 68:250-255, 2020.


Assuntos
Doença de Alzheimer/mortalidade , Assistência Terminal/estatística & dados numéricos , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Serviços de Assistência Domiciliar/estatística & dados numéricos , Instituição de Longa Permanência para Idosos/estatística & dados numéricos , Hospitais para Doentes Terminais/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Masculino , National Center for Health Statistics, U.S. , Casas de Saúde/estatística & dados numéricos , Distribuição por Sexo , Assistência Terminal/tendências , Estados Unidos/epidemiologia
11.
J Palliat Med ; 23(1): 90-96, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31424316

RESUMO

Background: Hospital referral regions (HRRs) are often used to characterize inpatient referral patterns, but it is unknown how well these geographic regions are aligned with variation in Medicare-financed hospice care, which is largely provided at home. Objective: Our objective was to characterize the variability in hospice use rates among elderly Medicare decedents by HRR and county. Methods: Using 2014 Master Beneficiary File for decedents 65 and older from North and South Carolina, we applied Bayesian mixed models to quantify variation in hospice use rates explained by HRR fixed effects, county random effects, and residual error among Medicare decedents. Results: We found HRRs and county indicators are significant predictors of hospice use in NC and SC; however, the relative variation within HRRs and associated residual variation is substantial. On average, HRR fixed effects explained more variation in hospice use rates than county indicators with a standard deviation (SD) of 10.0 versus 5.1 percentage points. The SD of the residual error is 5.7 percentage points. On average, variation within HRRs is about half the variation between regions (52%). Conclusions: The magnitude of unexplained residual variation in hospice use for NC and SC suggests that novel, end-of-life-specific service areas should be developed and tested to better capture geographic differences and inform research, health systems, and policy.

12.
J Nurs Scholarsh ; 52(1): 23-33, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31497935

RESUMO

PURPOSE: We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES). DESIGN: Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework. FINDINGS: Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention. CONCLUSIONS: The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment. CLINICAL RELEVANCE: This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.

14.
J Gen Intern Med ; 34(12): 2740-2748, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31452032

RESUMO

BACKGROUND: Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care. OBJECTIVE: To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke. DESIGN: Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605). MAIN MEASURES: Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated. KEY RESULTS: For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed. CONCLUSIONS: Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted. REGISTRATION: None.


Assuntos
Organizações de Assistência Responsáveis/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Acidente Vascular Cerebral/economia , Estados Unidos
16.
J Pain Symptom Manage ; 58(4): 654-661.e2, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31254641

RESUMO

CONTEXT: Palliative care improves patient and family outcomes and may reduce the cost of care, but this service is underutilized among Medicare beneficiaries. OBJECTIVES: To describe enrollment patterns and outcomes associated with the Center for Medicare and Medicaid Innovation expansion of a multisetting community palliative care program in North and South Carolina. METHODS: This observational study characterizes the Center for Medicare and Medicaid Innovation cohort's care and cost trajectories after enrollment. Program participants were age-eligible Medicare fee-for-service beneficiaries living in Western North Carolina and South Carolina who enrolled in a palliative care program from September 1, 2014, to August 31, 2017. End-of-life costs were compared between enrolled and nonenrolled decedents. Program administrative data and 100% Medicare claims data were used. RESULTS: A total of 5243 Medicare beneficiaries enrolled in the program from community (19%), facility (21%), small hospital (27%), or large hospital (33%) settings. Changes in Medicare expenditures in the 30 days after enrollment varied by setting. Adjusted odds of hospice use were 60% higher (OR = 1.60; CI = 1.47, 1.75) for enrolled decedents relative to nonenrolled decedents. Participants discharged to hospice vs. participants not had 17% (OR = 0.83 CI = 0.72, 0.94) lower costs. Among enrolled decedents those enrolled for at least 30 days vs. <30 days had 42% (OR = 0.58, CI = 0.49, 0.69) lower costs in the last 30 days of life. CONCLUSIONS: Expansion of community palliative care programs into multiple enrollment settings is feasible. It may improve hospice utilization among enrollees. Heterogeneous program participation by program setting pose challenges to a standardizing reimbursement policy.


Assuntos
Serviços de Saúde Comunitária/economia , Gastos em Saúde/estatística & dados numéricos , Medicare/economia , Cuidados Paliativos/economia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , North Carolina , South Carolina , Estados Unidos
17.
Health Aff (Millwood) ; 38(6): 1011-1020, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31158012

RESUMO

Care for people living with serious illness is suboptimal for many reasons, including underpayment for key services (such as care coordination and social supports) in fee-for-service reimbursement. Accountable care organizations (ACOs) have potential to improve serious illness care because of their widespread dissemination, strong financial incentives for care coordination in downside-risk models, and flexibility in shared savings spending. Through a national survey we found that 94 percent of ACOs at least partially identify their seriously ill beneficiaries, yet only 8-21 percent have widely implemented serious illness initiatives such as advance care planning or home-based palliative care. We selected six diverse ACOs with successful programs for case studies and interviewed fifty-three leaders and front-line personnel. Cross-cutting themes include the need for up-front investment beyond shared savings to build serious illness infrastructure and workforce; supporting the business case for organizational buy-in; how ACO contract specifications affect savings for serious illness populations; and using data and health information technology to manage populations. We discuss the implications of the recent Medicare ACO regulatory overhaul and other policies related to serious illness quality measures, risk adjustment, attribution methods, supporting rural ACOs, and enhancing timely data access.


Assuntos
Organizações de Assistência Responsáveis , Doença Crônica , Redução de Custos/economia , Gastos em Saúde/estatística & dados numéricos , Estudos de Casos Organizacionais , Cuidados Paliativos , Organizações de Assistência Responsáveis/economia , Organizações de Assistência Responsáveis/estatística & dados numéricos , Doença Crônica/economia , Doença Crônica/terapia , Planos de Pagamento por Serviço Prestado/economia , Humanos , Entrevistas como Assunto , Medicare/economia , Inovação Organizacional , Inquéritos e Questionários , Estados Unidos
19.
J Am Geriatr Soc ; 67(7): 1402-1409, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30835818

RESUMO

OBJECTIVES: Palliative care services have the potential to improve the quality of end-of-life care and reduce cost. Services such as the Medicare hospice benefit, however, are often underutilized among stroke patients with a poor prognosis. We tested the hypothesis that the Medicare Shared Savings Program (MSSP) is associated with increased hospice enrollment and inpatient comfort measures only among incident ischemic stroke patients with a high mortality risk. DESIGN: A difference-in-differences design was used to compare outcomes before and after hospital participation in the MSSP for patients discharged from MSSP hospitals (N = 273) vs non-MSSP hospitals (N = 1490). SETTING: Records from a national registry, Get with the Guidelines (GWTG)-Stroke, were linked to Medicare hospice claims (2010-2015). PARTICIPANTS: Fee-for-service Medicare beneficiaries age 65 and older hospitalized for incident ischemic stroke at a GWTG-Stroke hospital from January 2010 to December 2014 (N = 324 959). INTERVENTION: Discharge from an MSSP hospital or beneficiary alignment with an MSSP Accountable Care Organization (ACO). MEASUREMENTS: Hospice enrollment in the year following stroke. RESULTS: Among patients with high mortality risk, ACO alignment was associated with a 16% increase in odds of hospice enrollment (adjusted odds ratio [OR] = 1.16; 95% confidence interval [CI] = 1.06-1.26), increasing the probability of hospice enrollment from 20% to 22%. In the low mortality risk group, discharge from an MSSP vs non-MSSP hospital was associated with a decrease in the predicted probability of inpatient comfort measures or discharge to hospice from 9% to 8% (OR = .82; CI = .74-.91), and ACO alignment was associated with reduced odds of a short stay (<7 days) (OR = .86; CI = .77-.96). CONCLUSION: Among ischemic stroke patients with severe stroke or indicators of high mortality risk, MSSP was associated with increased hospice enrollment. MSSP contract incentives may motivate improved end-of-life care among the subgroups most likely to benefit.


Assuntos
Organizações de Assistência Responsáveis/economia , Isquemia Encefálica/terapia , Cuidados Paliativos na Terminalidade da Vida/economia , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Medicare/economia , Acidente Vascular Cerebral/terapia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/mortalidade , Planos de Pagamento por Serviço Prestado/economia , Feminino , Humanos , Masculino , Sistema de Registros , Acidente Vascular Cerebral/mortalidade , Assistência Terminal/economia , Estados Unidos/epidemiologia
20.
Med Care Res Rev ; 76(3): 255-290, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-29231131

RESUMO

Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Medicina Preventiva , Gerenciamento Clínico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Medicaid/organização & administração , Medicare/organização & administração , Qualidade da Assistência à Saúde , Estados Unidos
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