Endovascular repair is a less invasive strategy than open repair for the management of abdominal aortic aneurysm. This observational study in a large Medicare population shows that perioperative ...survival is superior with endovascular repair but that the survival advantage gradually wanes over 3 years. The survival advantage is more durable in older patients.
This observational study shows that perioperative survival is superior with endovascular repair but that the survival advantage gradually wanes over 3 years.
Since the first report of endovascular repair of abdominal aortic aneurysm in 1991, the technique has become a mainstay in the repair of abdominal aortic aneurysm, accounting for over 40% of elective repairs of abdominal aortic aneurysm in 2003 (Figure 1).
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Randomized trials have shown a perioperative survival benefit of endovascular repair over open repair, with fewer complications and a shorter recovery.
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There are concerns, however, that longer-term outcomes of endovascular repair may not be as durable as those of open repair, with endovascular repair increasing the risk of late rupture of the abdominal aortic aneurysm and necessitating . . .
IMPORTANCE: Recent US health care reforms incentivize improved population health outcomes and primary care functions. It remains unclear how much improving primary care physician supply can improve ...population health, independent of other health care and socioeconomic factors. OBJECTIVES: To identify primary care physician supply changes across US counties from 2005-2015 and associations between such changes and population mortality. DESIGN, SETTING, AND PARTICIPANTS: This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018. MAIN OUTCOMES AND MEASURES: Age-standardized life expectancy, cause-specific mortality, and restricted mean survival time. RESULTS: Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply. CONCLUSIONS AND RELEVANCE: Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.
In this study of abdominal aortic aneurysm repair, endovascular repair was shown to have an early survival advantage over open repair during the first three years. However, interventions related to ...aneurysm and ruptures were more common after endovascular repair.
The use of endovascular repair of abdominal aortic aneurysms is increasing. By 2010, endovascular repair accounted for 78% of all intact repairs.
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Randomized, controlled trials comparing endovascular repair with open repair generally have shown a perioperative benefit of endovascular repair over open repair.
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Long-term survival, however, is similar with the two approaches.
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As data on long-term outcomes accumulate, concerns have been raised about endovascular repair with respect to the increased rate of late failure leading to rupture and higher rates of reintervention.
In our previous analyses performed with the use of Medicare data, which account for more . . .
Measures of health care quality were compared between 246 hospitals that were acquired by another hospital or health system during 2009–2013 and 1986 control hospitals that were not acquired. A ...composite measure of patient-reported experience worsened slightly in acquired hospitals relative to control hospitals. There were no significant changes in mortality or readmission rates.
IMPORTANCE: Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care ...organization (ACO) programs, discourage the provision of low-value services. OBJECTIVE: To assess whether the first year of the Medicare Pioneer ACO program was associated with a reduction in use of low-value services. DESIGN, SETTING, AND PARTICIPANTS: In a difference-in-differences analysis, we compared use of low-value services between Medicare fee-for-service beneficiaries attributed to health care provider groups that entered the Pioneer program (ACO group) and beneficiaries attributed to other health care providers (control group) before (2009-2011) vs after (2012) Pioneer ACO contracts began. Data analysis was conducted from December 1, 2014, to June 27, 2015. Comparisons were adjusted for beneficiaries’ sociodemographic and clinical characteristics as well as for geography. We decomposed estimates according to service characteristics (clinical category, price, and sensitivity to patient preferences) and compared estimates between subgroups of ACOs with higher vs lower baseline use of low-value services. MAIN OUTCOMES AND MEASURES: Use of, and spending on, 31 services in instances that provide minimal clinical benefit, measured as annual service counts per 100 beneficiaries and price-standardized annual service spending per 100 beneficiaries. RESULTS: During the precontract period, trends in the use of low-value services were similar for the ACO and control groups. The first year of ACO contracts was associated with a differential reduction (95% CI) of 0.8 low-value services per 100 beneficiaries for the ACO group (−1.2 to −0.4; P < .001), corresponding to a 1.9% differential reduction in service quantity (−2.9% to −0.9%) and a 4.5% differential reduction in spending on low-value services (−7.5% to −1.4%; P = .004). Differential reductions were similar for services less sensitive vs more sensitive to patient preferences and for higher- vs lower-priced services. The ACOs with higher than their markets’ mean baseline levels of low-value service use experienced greater service reductions (−1.2 services per 100 beneficiaries; −1.7 to −0.7; P < .001) than did ACOs with use below the mean (−0.2 services per 100 beneficiaries, −0.6 to −0.2; P = .41; P = .003 for test of difference between subgroups). CONCLUSIONS AND RELEVANCE: During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low-value care. Accountable care organization–like risk contracts may be able to discourage use of low-value services even without specifying services to target.
A proposal from the Centers for Medicare and Medicaid Services would revise evaluation-and-management payments but would maintain features of the current system for assigning relative value units to ...services that have exacerbated distortions in payment.
Background
The patient centered medical home has received considerable attention as a potential way to improve primary care quality and limit cost growth. Little information exists that ...systematically compares PCMH pilot projects across the country.
Design
Cross-sectional key-informant interviews.
Participants
Leaders from existing PCMH demonstration projects with external payment reform.
Measurements
We used a semi-structured interview tool with the following domains: project history, organization and participants, practice requirements and selection process, medical home recognition, payment structure, practice transformation, and evaluation design.
Results
A total of 26 demonstrations in 18 states were interviewed. Current demonstrations include over 14,000 physicians caring for nearly 5 million patients. A majority of demonstrations are single payer, and most utilize a three component payment model (traditional fee for service, per person per month fixed payments, and bonus performance payments). The median incremental revenue per physician per year was $22,834 (range $720 to $91,146). Two major practice transformation models were identified—consultative and implementation of the chronic care model. A majority of demonstrations did not have well-developed evaluation plans.
Conclusion
Current PCMH demonstration projects with external payment reform include large numbers of patients and physicians as well as a wide spectrum of implementation models. Key questions exist around the adequacy of current payment mechanisms and evaluation plans as public and policy interest in the PCMH model grows.
Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for ...the range of care coordination needed in primary care.
To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination.
Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time.
Traditional fee-for-service Medicare.
20% sample of Medicare beneficiaries.
Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients.
The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019.
Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel.
Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs.
National Institute on Aging.
Only a small proportion of people with a substance use disorder (SUD) receive treatment. The shortage of SUD treatment providers, particularly in rural areas, is an important driver of this treatment ...gap. Telemedicine could be a means of expanding access to treatment. However, several key regulatory and reimbursement barriers to greater use of telemedicine for SUD (tele-SUD) exist, and both Congress and the states are considering or have recently passed legislation to address them. To inform these efforts, we describe how tele-SUD is being used. Using claims data for 2010-17 from a large commercial insurer, we identified characteristics of tele-SUD users and examined how tele-SUD is being used in conjunction with in-person SUD care. Despite a rapid increase in tele-SUD over the study period, we found low use rates overall, particularly relative to the growth in telemental health. Tele-SUD is primarily used to complement in-person care and is disproportionately used by those with relatively severe SUD. Given the severity of the opioid epidemic, low rates of tele-SUD use represent a missed opportunity. As tele-SUD becomes more available, it will be important to monitor closely which tele-SUD delivery models are being used and their impact on access and outcomes.