The Center for Medicare and Medicaid Innovation revised the comprehensive Care for Joint Replacement (CJR) program, a mandatory 90-day bundled payment for lower extremity joint replacement, in ...December 2017, retaining 34 of the original 67 metropolitan statistical areas with higher volume and historic episode payments.
We describe differences in costs, quality, and patient selection between hospitals that continued to participate compared with those that withdrew from CJR before and after the implementation of CJR.
We used a triple difference approach to compare the magnitude of the policy effect for elective admissions between hospitals that were retained in the CJR revision or not, before and after the implementation of CJR, and compared with hospitals in nonparticipant metropolitan statistical areas.
694,275 Medicare beneficiaries undergoing elective lower extremity joint replacement from January 1, 2013 to August 31, 2017.
The treatment effect heterogeneity of CJR.
Hospitals retained in the CJR policy revision had a greater reduction in 90-day episode-of-care cost compared with those that were allowed to discontinue (-$846, 95% CI: -$1,338, -$435) and had greater cost reductions in the more recent year (2017). We also found evidence that retained CJR hospitals disproportionately reduced treating patients who were older than 85 years.
Hospitals that continued to participate in CJR after the policy revision achieved a greater cost reduction. However, the cost reductions were partly attributed to avoiding potential higher - cost patients, suggesting that a bundled payment policy might induce disparities in care delivery.
Creative arts therapies aim to expand conventional palliative care interventions by making clinical care more holistic.
The objective of the present study was to evaluate the benefits of an art ...therapy intervention in a tertiary hospital palliative care unit, directly in adult cancer inpatients and indirectly in their relatives.
We evaluated the intensity of pain, anxiety, depression, and well-being using the Edmonton Symptom Assessment Scale before and after the first, third, and fifth art therapy sessions. After the third and fifth sessions, perceived helpfulness was assessed via a questionnaire developed by the palliative care team, combining open-ended questions and a checklist. We categorized the narrative data into three predetermined types: generally helpful (some positive experience), helpfulness related to a dyadic relationship (patient-art therapist), and helpfulness related to a triadic relationship (patient-image-art therapist).
We observed a significant reduction in anxiety, depression, and pain as well as a significant increase in well-being at each of the time points evaluated. Ninety-eight percent of the patients considered the art therapy helpful, which could be categorized as generally helpful in 54.8%, related to a triadic relationship in 32.9%, and to a dyadic relationship in 12.3%. Relatives gave similar opinions regarding the effects on patients and, in addition, reported an indirect helpful effect for themselves. The most frequently selected experiences from the checklist were feeling calm, being entertained, and expressing and communicating emotions.
This art therapy intervention was beneficial in reducing symptom intensity. Almost all the participants directly or indirectly involved in the creative art process considered it helpful. They reported a wide variety of sensory, emotional, cognitive, and spiritual experiences.
Covid-19 is a novel infectious disease whose spectrum of presentation ranges from absence of symptoms to widespread interstitial pneumonia associated with severe acute respiratory syndrome (SARS), ...leading to significant mortality. Given the systemic pattern of Covid-19, there are many factors that can influence patient's functional capacity after acute infection and the identification of such factors can contribute to the development of specific rehabilitation strategies. Pulmonary impairment is the primary cause of hospitalization due to Covid-19, and can progress to SARS as well as increase length of hospitalization. Moreover, cardiac involvement is observed in approximately 30% of hospitalized patients, with an increased risk of acute myocarditis, myocardial injury, and heart failure, which may compromise functional capacity in the long-term. Thromboembolic complications have also been reported in some patients with Covid-19 and are associated with a poor prognosis. Musculoskeletal complications may result from long periods of hospitalization and immobility, and can include fatigue, muscle weakness and polyneuropathy. Studies that address the functional capacity of patients after Covid-19 infection are still scarce. However, based on knowledge from the multiple systemic complications associated with Covid-19, it is reasonable to suggest that most patients, especially those who underwent prolonged hospitalization, will need a multiprofessional rehabilitation program. Further studies are needed to evaluate the functional impact and the rehabilitation strategies for patients affected by Covid-19.
Introduction: Haemophilia management and patients’ quality of life significantly improved. However, data on current patients’, caregivers’ and clinicians’ satisfaction and limitations of treatments ...and haemophilia management are limited.
Aim: Assessing the management satisfaction and unmet needs from the perspective of Italian patients with haemophilia (PWH) without inhibitors (or caregivers if children) and of specialist physicians.
Methods: Surveys (for patients≥18 years, caregivers of children and haemophilia specialists) were developed by a multidisciplinary working group and conducted from November 2019 to June 2020.
Results: Among 275 participants, 120 (43.6%) were PWH without inhibitors, 79 (28.7%) caregivers and 37 (13.4%) clinicians. Patients and caregivers perceived a higher control of the disease compared to clinicians. However, more than 40% of patients and caregivers reported to feel significantly conditioned by the risk of bleeding during their daily life. PWH reported a 6‐month mean/median (range) of bleeds 2.3/.0 (0‐24) and caregivers 1.3/.0 (0‐16) in children. The treatment burden (frequency of administration) was not satisfactory for more than half adults and caregivers of children treated with prophylaxis. A good access to treatment, haemophilia centres and medical service was reported, with issues associated to the multidisciplinary approach and treatment at emergency department.
Conclusions: This large national study provides an updated overview of haemophilia care in Italy from different points of views, highlighting positive aspects and unmet needs. This information can guide future interventions to improve haemophilia management and the assessment of impact of new treatment options.
Team-based primary care offers a wide range of health services to patients by using interdisciplinary health care providers committed to delivering comprehensive, coordinated and high-quality care ...through team collaboration. Ontario's Family Health Team (FHT), the largest team-based practice model in Canada, was introduced to improve access to and effectiveness of primary health care services, and was available primarily for physicians paid under blended capitation models (Family Health Organizations and Family Health Networks). Using health administrative data on physicians practicing under blended capitation models in Ontario between 2006 and 2015, we study the impact of switching from non-FHT to FHTs on the production of capitated comprehensive care services, after-hours services, non-incentivized services, and services provided to non-enrolled patients by family physicians. We find that when in FHTs, physicians increase the production of total services and non-incentivized services by 26% and 5% per annum and reduce capitated comprehensive care services by 3.2% per annum. When in FHTs, physicians also see and enroll more patients relative to those practicing in non-FHTs. We find evidence of improved access to physician's services under team-based primary care, but switching to FHTs has no effect on the production of after-hours services and services provided to non-enrolled patients.
•Team-based primary care increases the production of physician's services.•Patient enrollment by physicians increases in an interdisciplinary team.•Team-based practice reduces comprehensive services and increases other services.•Substitution between services by physicians in a team may be due to tasks shifting.
Background: While the comprehensive care for joint replacement (CJR) bundled payment program for total joint replacement (TJR) emphasizes value, concerns persist regarding unintended consequences, ...primarily hospital selection of healthier, younger patients. Purpose: We sought to assess changes in patient characteristics and outcomes after CJR implementation in New York State. Methods: This retrospective cohort study included primary total hip and total knee arthroplasties from the New York Statewide Planning and Research Cooperative System (SPARCS) database. Procedures performed before (July 2014 to March 2016; n = 58,610) and after (April 2016 to December 2017; n = 78,728) CJR implementation were compared. Primary outcomes were patient characteristics: Deyo-Comorbidity Index and age. Secondary outcomes were increased hospitalization cost, discharge to institutional post-acute care, and prolonged length of stay. A difference-in-differences analysis estimated changes after CJR implementation, comparing CJR to non-CJR hospitals. Results: We found that CJR implementation (in 49 of 144 New York State hospitals) coincided with slightly older and more comorbid TJR recipients. The CJR program coincided with significantly reduced hospitalization cost and discharge to institutional post-acute care but not length of stay. Some CJR effects appear to have affected non-Medicare patients, as well. Conclusion: This retrospective analysis suggests that in New York State, the CJR bundled payment program did not result in hospitals selecting younger and healthier TJR recipients and coincided with decreased costs and fewer discharges to institutional postacute care.
Older adult patients account for 70% of all hospitalized patients in Japan, and intermediate care based on patient-centered care (PCC) that ensures continuity and quality of care at the interface ...between home services and acute care services and restores patient's independence and confidence is necessary for them to continue living independently. At present, no concept of intermediate care is established in Japan, and the implementation of PCC has been delayed. Thus, in this study, a Japanese version of the intermediate care evaluation index (patient-reported experience measure (PREM)) was created on the basis of the original PREM developed in the UK, and data in wards with intermediate care functions in Japan were collected to confirm internal consistency and validity from 2020 to 2022. The Japanese version of PREM was found to have a factor structure with two potential factors. Given the clear correlation with the shared decision-making evaluation index, which is the pinnacle of PCC, the theoretical validity of the Japanese version of PREM, which is based on PCC as a theoretical basis, was confirmed.
Sickle cell disease (SCD) is the most common life-threatening monogenic disorder in the world. The disease is highly prevalent in malaria endemic areas with over 75% of patients residing in ...Sub-Saharan Africa (SSA). It is estimated that, without proper care, up to 90% of children with SCD will not celebrate their fifth birthday. Early identification and enrolment into comprehensive care has been shown to reduce the morbidity and mortality related with SCD complications. However, due to resource constraints, the SSA is yet to implement universal newborn screening programs for SCD. Furthermore, care for patients with SCD in the region is hampered by the shortage of qualified healthcare workers, lack of guidelines for the clinical management of SCD, limited infrastructure for inpatient and outpatient care, and limited access to blood and disease modifying drugs such as Hydroxyurea which contribute to poor clinical outcomes. Curative options such as bone marrow transplant and gene therapy are expensive and not available in many SSA countries. In addressing these challenges, various initiatives are ongoing in SSA which aim to enhance awareness on SCD, improve patient identification and retention to care, harmonize the standards of care for SCD, improve the skills of healthcare workers and conduct research on pertinent areas in SCD in the SSA context. Fortifying these measures is paramount to improving the outcomes of SCD in SSA.
The impact of a new class of automated digital patient engagement (DPE) platforms on potentially avoidable costs, hospital admissions, and complications after discharge following hip and knee ...arthroplasties has not been established.
We conducted a multicenter observational cohort study comparing claims data for potentially avoidable costs, hospital admissions, and complications for 90 days after discharge following hip and knee arthroplasties at 10 practice sites in CA and NV. One hundred eighty-six patients, enrolled between 2014 and 2016 on an automated DPE platform receiving guidance and remote monitoring perioperatively, were compared with 372 patients who underwent the same procedures from the same physicians within 3 years immediately preceding platform implementation. The primary end point was the proportion of patients with $0.00 in 90-day target costs because of potentially avoidable utilization within the platform's influence. Secondary end points included rates of potentially avoidable 90-day hospital admissions and composite complications.
Ninety-three percent and 84.7% of the study and baseline cohorts, respectively, had $0.00 in target costs (P = .004), with a mean savings of $656.52/patient (P = .006). The baseline and study cohorts had 3.0% and 1.6% 90-day hospital admission rates (relative risk 0.545; 0.154, 1.931, P = .40), and 15.3% and 7.0% composite complication rates, respectively (relative risk 0.456; 0.256, 0.812, P = .004).
Patients enrolled on an automated DPE platform after hip and knee arthroplasties demonstrated a significant reduction in potentially avoidable 90-day costs, a 45.4% nonsignificant relative reduction in 90-day hospital admissions, and a 54.4% significant relative reduction in 90-day complications.
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