Base de dados : MEDLINE
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[PMID]:29360300
[Au] Autor:Thomson Reuters Accelus.
[Ti] Título:Healthcare Reform: Payment Reform.
[So] Source:Issue Brief Health Policy Track Serv;2017:1-42, 2017 Dec 26.
[Cp] País de publicação:United States
[La] Idioma:eng
[Mh] Termos MeSH primário: Reforma dos Serviços de Saúde/economia
Reembolso de Seguro de Saúde
Mecanismo de Reembolso/organização & administração
[Mh] Termos MeSH secundário: Organizações de Assistência Responsáveis
Redução de Custos
Cuidado Periódico
Reforma dos Serviços de Saúde/organização & administração
Serviços de Assistência Domiciliar
Seres Humanos
Medicare
Neoplasias/economia
Neoplasias/terapia
Projetos Piloto
Atenção Primária à Saúde
Garantia da Qualidade dos Cuidados de Saúde/economia
Reembolso de Incentivo
Cuidados Semi-Intensivos/economia
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1802
[Cu] Atualização por classe:180219
[Lr] Data última revisão:
180219
[Sb] Subgrupo de revista:T
[Da] Data de entrada para processamento:180124
[St] Status:MEDLINE


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[PMID]:27776908
[Au] Autor:Weeks WB; Schoellkopf WJ; Sorensen LS; Masica AL; Nesse RE; Weinstein JN
[Ad] Endereço:The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; Geisel School of Medicine, Hanover, New Hampshire.
[Ti] Título:The High Value Healthcare Collaborative: Observational Analyses of Care Episodes for Hip and Knee Arthroplasty Surgery.
[So] Source:J Arthroplasty;32(3):702-708, 2017 03.
[Is] ISSN:1532-8406
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:BACKGROUND: Broader use of value-based reimbursement models will require providers to transparently demonstrate health care value. We sought to determine and report cost and quality data for episodes of hip and knee arthroplasty surgery among 13 members of the High Value Healthcare Collaborative (HVHC), a consortium of health care systems interested in improving health care value. METHODS: We conducted a retrospective, cross-sectional observational cohort study of 30-day episodes of care for hip and knee arthroplasty in fee-for-service Medicare beneficiaries aged 65 or older who had hip or knee osteoarthritis and used 1 of 13 HVHC member systems for uncomplicated primary hip arthroplasty (N = 8853) or knee arthroplasty (N = 16,434), respectively, in 2012 or 2013. At the system level, we calculated: per-capita utilization rates; postoperative complication rates; standardized total, acute, and postacute care Medicare expenditures for 30-day episodes of care; and the modeled impact of reducing episode expenditures or per-capita utilization rates. RESULTS: Adjusted per-capita utilization rates varied across HVHC systems and postacute care reimbursements varied more than 3-fold for both types of arthroplasty in both years. Regression analysis confirmed that total episode and postacute care reimbursements significantly differed across HVHC members after considering patient demographic differences. Potential Medicare cost savings were greatest for knee arthroplasty surgery and when lower total reimbursement targets were achieved. CONCLUSION: The substantial variation that we found offers opportunities for learning and collaboration to collectively improve outcomes, reduce costs, and enhance value. Ceteris paribus, reducing per-episode reimbursements would achieve greater Medicare cost savings than reducing per-capita rates.
[Mh] Termos MeSH primário: Artroplastia de Quadril/economia
Artroplastia do Joelho/economia
Complicações Pós-Operatórias/epidemiologia
[Mh] Termos MeSH secundário: Idoso
Artroplastia de Quadril/utilização
Artroplastia do Joelho/utilização
Redução de Custos
Estudos Transversais
Assistência à Saúde
Cuidado Periódico
Planos de Pagamento por Serviço Prestado
Feminino
Gastos em Saúde
Seres Humanos
Tempo de Internação
Masculino
Medicare/economia
Meia-Idade
Osteoartrite do Joelho
Análise de Regressão
Estudos Retrospectivos
Cuidados Semi-Intensivos
Estados Unidos/epidemiologia
[Pt] Tipo de publicação:JOURNAL ARTICLE; RESEARCH SUPPORT, U.S. GOV'T, NON-P.H.S.
[Em] Mês de entrada:1711
[Cu] Atualização por classe:171222
[Lr] Data última revisão:
171222
[Sb] Subgrupo de revista:IM
[Da] Data de entrada para processamento:161026
[St] Status:MEDLINE


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[PMID]:29077945
[Au] Autor:Lee N; Thompson NR; Passek S; Stilphen M; Katzan IL
[Ad] Endereço:Medicine Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195.
[Ti] Título:Minimally Clinically Important Change in the Activity Measure for Post-Acute Care (AM-PAC), a Generic Patient-Reported Outcome Tool, in People With Low Back Pain.
[So] Source:Phys Ther;97(11):1094-1102, 2017 Nov 01.
[Is] ISSN:1538-6724
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:Background: The Activity Measure for Post-Acute Care (AM-PAC) is a generic metric of patient-reported functional status. The minimal clinically important difference (MCID) in the AM-PAC score has not been determined. Objective: The study objective was to determine the MCID for AM-PAC in people with low back pain. Design: This was a retrospective cohort study. Methods: Anchor-based and distribution-based methods were used to estimate the MCID. The Modified Low Back Pain Disability Questionnaire was used as the anchor. Adults who had a primary ICD-9 code for low back pain in at least 1 outpatient physical therapist visit during an episode of care and who completed both the AM-PAC and the Modified Low Back Pain Disability Questionnaire in at least 2 visits during the care episode were included. The MCID was calculated for the AM-PAC basic mobility version as well its adapted version, which the Cleveland Clinic uses for patients 65 years old or older. Results: A total of 1,271 participants were eligible for study. For the AM-PAC basic mobility version, anchor-based methods yielded MCID estimates of between 3.4 and 5.1, whereas distribution-based methods yielded estimates of 1.7 to 4.2. The minimal detectable change (MDC) for the AM-PAC basic mobility version was 3.3. For the adapted AM-PAC basic mobility version, the MCID was estimated to be between 2.9 and 4.0 via anchor-based methods and between 1.2 to 3.5 via distribution-based methods. The MDC for the adapted AM-PAC basic mobility version was 3.5. Limitations: The estimated MCID was designed for people with low back pain only. Conclusions: The MCID ranged from 3.3 to 5.1 for the AM-PAC basic mobility version and 3.5 to 4 for the adapted version, with the MDC as the lower limit. Changes in the AM-PAC for people with low back pain may be interpreted using the estimated MCID. Future studies are needed to determine the AM-PAC MCID for populations other than those with low back pain.
[Mh] Termos MeSH primário: Exercício
Dor Lombar/fisiopatologia
Dor Lombar/terapia
Diferença Mínima Clinicamente Importante
Cuidados Semi-Intensivos
[Mh] Termos MeSH secundário: Adulto
Avaliação da Deficiência
Feminino
Seres Humanos
Dor Lombar/psicologia
Masculino
Meia-Idade
Medição da Dor
Medidas de Resultados Relatados pelo Paciente
Estudos Retrospectivos
Inquéritos e Questionários
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1711
[Cu] Atualização por classe:171113
[Lr] Data última revisão:
171113
[Sb] Subgrupo de revista:AIM; IM
[Da] Data de entrada para processamento:171028
[St] Status:MEDLINE
[do] DOI:10.1093/ptj/pzx083


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[PMID]:28855001
[Au] Autor:Grosso MB
[Ti] Título:Helping the Long-Term/Post-Acute Care Facility Manage Influenza.
[So] Source:Consult Pharm;32(Suppl C):14-24, 2017 Sep 01.
[Is] ISSN:0888-5109
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:Improving the health of Americans by increasing influenza immunization among health care workers and institutionalized older adults--to 90% by 2020-is a a national goal. Pharmacists practicing in the long-term/post-acute care sector are in a unique position to positively affect the achievement of this goal. These facilities often look to the pharmacist for clinical expertise as well as assistance with strategic planning for the influenza season, staff education, and reimbursement.
[Mh] Termos MeSH primário: Influenza Humana/prevenção & controle
Assistência de Longa Duração
Farmacêuticos
Papel Profissional
Cuidados Semi-Intensivos
[Mh] Termos MeSH secundário: Idoso
Pessoal de Saúde
Seres Humanos
Vacinação
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1711
[Cu] Atualização por classe:171107
[Lr] Data última revisão:
171107
[Sb] Subgrupo de revista:IM
[Da] Data de entrada para processamento:170901
[St] Status:MEDLINE
[do] DOI:10.4140/TCP.s.2017.014


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[PMID]:28809645
[Au] Autor:Giles GM; Edwards DF; Morrison MT; Baum C; Wolf TJ
[Ad] Endereço:Gordon Muir Giles, PhD, OTR/L, FAOTA, is Professor, Samuel Merritt University, Oakland, CA, and Director of Neurobehavioral Services, Crestwood Behavioral Health, Inc., Sacramento, CA; ggiles@samuelmerritt.edu.
[Ti] Título:Screening for Functional Cognition in Postacute Care and the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014.
[So] Source:Am J Occup Ther;71(5):7105090010p1-7105090010p6, 2017 Sep/Oct.
[Is] ISSN:0272-9490
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:Occupational therapists have a long history of assessing functional cognition, defined as the ability to use and integrate thinking and performance skills to accomplish complex everyday activities. In response to passage of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 (Pub. L. 113-185), the American Occupational Therapy Association has been advocating that the Centers for Medicare and Medicaid Services consider functional cognition for inclusion in routine patient assessment in postacute care settings, with important implications for occupational therapy. These efforts have the potential to increase referrals to occupational therapy, emphasize the importance of addressing functional cognition in occupational therapy practice, and support the value of occupational therapy in achieving optimal postacute care outcomes.
[Mh] Termos MeSH primário: Atividades Cotidianas
Cognição
Disfunção Cognitiva/diagnóstico
Política de Saúde/legislação & jurisprudência
Terapia Ocupacional
Cuidados Semi-Intensivos/métodos
[Mh] Termos MeSH secundário: Seres Humanos
Programas de Rastreamento
Medicare
Mecanismo de Reembolso
Reembolso de Incentivo
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1711
[Cu] Atualização por classe:171102
[Lr] Data última revisão:
171102
[Sb] Subgrupo de revista:IM
[Da] Data de entrada para processamento:170816
[St] Status:MEDLINE
[do] DOI:10.5014/ajot.2017.715001


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[PMID]:28636200
[Au] Autor:Greysen SR; Stijacic Cenzer I; Boscardin WJ; Covinsky KE
[Ad] Endereço:Section of Hospital Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
[Ti] Título:Functional Impairment: An Unmeasured Marker of Medicare Costs for Postacute Care of Older Adults.
[So] Source:J Am Geriatr Soc;65(9):1996-2002, 2017 Sep.
[Is] ISSN:1532-5415
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:OBJECTIVES: To assess the effects of preadmission functional impairment on Medicare costs of postacute care up to 365 days after hospital discharge. DESIGN: Longitudinal cohort study. SETTING: Health and Retirement Study (HRS). PARTICIPANTS: Nationally representative sample of 16,673 Medicare hospitalizations of 8,559 community-dwelling older adults from 2000 to 2012. MEASUREMENTS: The main outcome was total Medicare costs in the year after hospital discharge, assessed according to Medicare claims data. The main predictor was functional impairment (level of difficulty or dependence in activities of daily living (ADLs)), determined from HRS interview preceding hospitalization. Multivariable linear regression was performed, adjusted for age, race, sex, income, net worth, and comorbidities, with clustering at the individual level to characterize the association between functional impairment and costs of postacute care. RESULTS: Unadjusted mean Medicare costs for 1 year after discharge increased with severity of impairment in a dose-response fashion (P < .001 for trend); 68% had no functional impairment ($25,931), 17% had difficulty with one ADL ($32,501), 7% had dependency in one ADL ($39,928), and 8% had dependency in two or more ADLs ($45,895). The most severely impaired participants cost 77% more than those with no impairment; adjusted analyses showed attenuated effect size (33% more) but no change in trend. Considering costs attributable to comorbidities, only three conditions were more expensive than severe functional impairment (lymphoma, metastatic cancer, paralysis). CONCLUSION: Functional impairment is associated with greater Medicare costs for postacute care and may be an unmeasured but important marker of long-term costs that cuts across conditions.
[Mh] Termos MeSH primário: Atividades Cotidianas
Pessoas com Deficiência/psicologia
Hospitalização
Medicare/economia
Cuidados Semi-Intensivos/economia
[Mh] Termos MeSH secundário: Idoso
Estudos de Coortes
Feminino
Seres Humanos
Masculino
Fatores de Risco
Inquéritos e Questionários
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1709
[Cu] Atualização por classe:171013
[Lr] Data última revisão:
171013
[Sb] Subgrupo de revista:IM
[Da] Data de entrada para processamento:170622
[St] Status:MEDLINE
[do] DOI:10.1111/jgs.14955


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[PMID]:28398964
[Au] Autor:Balentine CJ; Richardson PA; Mason MC; Naik AD; Berger DH; Anaya DA
[Ad] Endereço:*Department of Surgery, University of Wisconsin, Madison, WI†Houston Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX‡Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX§Alkek Department of Medicine, Baylor College of Medicine, Houston, TX¶Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
[Ti] Título:Postacute Care and Recovery After Cancer Surgery: Still a Long Way to Go.
[So] Source:Ann Surg;265(5):993-999, 2017 May.
[Is] ISSN:1528-1140
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:OBJECTIVE: To determine whether postacute care (PAC) facilities can compensate for increased mortality stemming from a complicated postoperative recovery (complications or deconditioning). BACKGROUND: An increasing number of patients having cancer surgery rely on PAC facilities including skilled nursing and rehabilitation centers to help them recover from postoperative complications and the physical demands of surgery. It is currently unclear whether PAC can successfully compensate for the adverse consequences of a complicated postoperative recovery. METHODS: We combined data from the Veterans Affairs Cancer Registry with the Surgical Quality Improvement Program to identify veterans having surgery for stage I-III colorectal cancer from 1999 to 2010. We used propensity matching to control for comorbidity, functional status, postoperative complications, and stage. RESULTS: We evaluated 10,583 veterans having colorectal cancer surgery, and 765 veterans (7%) were discharged to PAC facilities whereas 9818 veterans (93%) were discharged home. Five-year overall survival after discharge to PAC facilities was 36% compared with 51% after discharge home. Stage I patients discharged to PAC facilities had similar survival (45%) as stage III patients who were discharged home (44%). Patients discharged to PAC facilities had worse survival in the first year after surgery (hazard ratio 2.0, 95% confidence interval 1.7-2.4) and after the first year (hazard ratio 1.4, 95% confidence interval 1.2-1.5). CONCLUSIONS: Discharge to PAC facilities after cancer surgery is not sufficient to overcome the adverse survival effects of a complicated postoperative recovery. Improvement of perioperative care outside the acute hospital setting and development of better postoperative recovery programs for cancer patients are needed to enhance survival after surgery.
[Mh] Termos MeSH primário: Neoplasias Colorretais/cirurgia
Cirurgia Colorretal/métodos
Cuidados Semi-Intensivos/normas
[Mh] Termos MeSH secundário: Idoso
Idoso de 80 Anos ou mais
Estudos de Coortes
Neoplasias Colorretais/mortalidade
Neoplasias Colorretais/patologia
Cirurgia Colorretal/efeitos adversos
Feminino
Seguimentos
Mortalidade Hospitalar
Seres Humanos
Tempo de Internação
Masculino
Meia-Idade
Determinação de Necessidades de Cuidados de Saúde
Cuidados Pós-Operatórios/métodos
Complicações Pós-Operatórias/fisiopatologia
Complicações Pós-Operatórias/terapia
Recuperação de Função Fisiológica
Estudos Retrospectivos
Cuidados Semi-Intensivos/tendências
Análise de Sobrevida
Resultado do Tratamento
Estados Unidos
[Pt] Tipo de publicação:EVALUATION STUDIES; JOURNAL ARTICLE
[Em] Mês de entrada:1706
[Cu] Atualização por classe:170609
[Lr] Data última revisão:
170609
[Sb] Subgrupo de revista:AIM; IM
[Da] Data de entrada para processamento:170412
[St] Status:MEDLINE
[do] DOI:10.1097/SLA.0000000000001758


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[PMID]:28338215
[Au] Autor:Kosar CM; Thomas KS; Inouye SK; Mor V
[Ad] Endereço:Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.
[Ti] Título:Delirium During Postacute Nursing Home Admission and Risk for Adverse Outcomes.
[So] Source:J Am Geriatr Soc;65(7):1470-1475, 2017 Jul.
[Is] ISSN:1532-5415
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:OBJECTIVES: To identify the rate of delirium present during admission to postacute care (PAC) in the nursing home setting and to determine whether patients with delirium had higher risk for adverse outcomes. DESIGN: Retrospective cohort study. SETTING: US Medicare- and Medicaid-certified nursing homes, 2011 to 2014. PARTICIPANTS: Individuals admitted to all US nursing homes for PAC, aged ≥65 years, and without prior history of nursing home residence (n = 5,588,702). MEASUREMENTS: Minimum Data Set (MDS) 3.0 admission assessments identified delirium based upon Confusion Assessment Method (CAM) items. Robust Poisson regression was used to calculate adjusted relative risks (aRRs) with 95% confidence intervals (CIs) for death following PAC admission, and for 30-day discharge outcomes including re-hospitalization from PAC, discharge home, and functional improvement. RESULTS: Delirium was identified in 4.3% of new postacute nursing home admissions. Mortality within 30 days of PAC admission was observed in 16.3% of patients with delirium and 5.8% of patients without delirium (aRR = 2.27, CI = 2.24-2.30). The rate of 30-day readmission from PAC was 21.3% for patients with delirium compared with 15.1% among patients without delirium (aRR = 1.42, 95% CI = 1.40, 1.43). 26.9% of patients with delirium were discharged home within 30 days of admission compared to 52.5% of patients without delirium (aRR = 0.57, 95% CI = 0.57, 0.58). 48.9% of patients with delirium showed functional improvement at discharge compared to 59.9% of patients without delirium (aRR = 0.83, 95% CI = 0.82, 0.83). CONCLUSIONS: Patients with delirium present upon PAC admission were at high risk for mortality and 30-day re-hospitalization and were less likely to have timely discharge to home or to improve in physical function at discharge. Early identification and care planning for individuals with delirium at PAC admission may be essential to improve outcomes.
[Mh] Termos MeSH primário: Delírio/epidemiologia
Delírio/mortalidade
Casas de Saúde
Cuidados Semi-Intensivos
[Mh] Termos MeSH secundário: Idoso
Idoso de 80 Anos ou mais
Feminino
Hospitalização
Seres Humanos
Masculino
Medicaid
Medicare
Alta do Paciente/estatística & dados numéricos
Readmissão do Paciente/estatística & dados numéricos
Estudos Retrospectivos
Risco
Inquéritos e Questionários
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1708
[Cu] Atualização por classe:170807
[Lr] Data última revisão:
170807
[Sb] Subgrupo de revista:IM
[Da] Data de entrada para processamento:170325
[St] Status:MEDLINE
[do] DOI:10.1111/jgs.14823


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[PMID]:28255991
[Au] Autor:Horney C; Capp R; Boxer R; Burke RE
[Ad] Endereço:Department of Medicine, Division of Geriatric Medicine, University of Colorado, Aurora, Colorado.
[Ti] Título:Factors Associated With Early Readmission Among Patients Discharged to Post-Acute Care Facilities.
[So] Source:J Am Geriatr Soc;65(6):1199-1205, 2017 Jun.
[Is] ISSN:1532-5415
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:BACKGROUND: Over a quarter of Medicare patients admitted to the hospital are discharged to post-acute care (PAC) facilities, but face high rates of readmission. Timing of readmission may be an important factor in identifying both risk for and preventability of future readmissions. This study aims to define factors associated with readmission within the first week of discharge to PAC facilities following hospitalization. DESIGN AND MEASUREMENTS: This was a secondary analysis of the 2011 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for California, Massachusetts, and Florida. The primary outcome was all-cause readmission within 7 days after hospital discharge, compared to readmission on days 8-30, for patients aged 65 and older who were discharged from the hospital to a PAC facility. Predictor variables included patient, index hospitalization, and hospital characteristics; multivariable logistic regression was used to identify significant predictors of readmission within 7 days. RESULTS: There were 81,173 hospital readmissions from PAC facilities in the first 30 days after hospital discharge. Patients readmitted within the first week were older, white, urban, had fewer comorbid illnesses, had a higher number of previous hospital admissions, and less commonly had Medicare as a payer. Longer index hospital length of stay (LOS) was associated with decreased risk of early readmission (OR 0.74; 95% CI 0.70-0.74 for LOS 4-7 days and 0.60; 95% CI 0.56-0.64 for LOS ≥8 days). CONCLUSIONS: Shorter length of index hospital stay is associated with earlier readmission and suggests that for this comorbid, older population, a shorter hospital stay may be detrimental. Readmission after 1 week is associated with increased chronic disease burden, suggesting they may be associated with factors that are less modifiable.
[Mh] Termos MeSH primário: Alta do Paciente/estatística & dados numéricos
Readmissão do Paciente/estatística & dados numéricos
Cuidados Semi-Intensivos/estatística & dados numéricos
[Mh] Termos MeSH secundário: Idoso de 80 Anos ou mais
Bases de Dados Factuais
Feminino
Hospitalização
Seres Humanos
Tempo de Internação/estatística & dados numéricos
Masculino
Medicare/economia
Instituições de Cuidados Especializados de Enfermagem/utilização
Fatores de Tempo
Estados Unidos
[Pt] Tipo de publicação:JOURNAL ARTICLE
[Em] Mês de entrada:1708
[Cu] Atualização por classe:170928
[Lr] Data última revisão:
170928
[Sb] Subgrupo de revista:IM
[Da] Data de entrada para processamento:170304
[St] Status:MEDLINE
[do] DOI:10.1111/jgs.14758


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[PMID]:28192556
[Au] Autor:McWilliams JM; Gilstrap LG; Stevenson DG; Chernew ME; Huskamp HA; Grabowski DC
[Ad] Endereço:Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
[Ti] Título:Changes in Postacute Care in the Medicare Shared Savings Program.
[So] Source:JAMA Intern Med;177(4):518-526, 2017 Apr 01.
[Is] ISSN:2168-6114
[Cp] País de publicação:United States
[La] Idioma:eng
[Ab] Resumo:Importance: Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care. Objective: To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred. Design, Setting, and Participants: With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014. Exposures: Patient attribution to an ACO in the MSSP. Main Outcomes and Measures: Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics. Results: For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (-$27 per beneficiary [95% CI, -$49 to -$6], or -3.3% of the precontract unadjusted mean of $813; P = .01) but not in the 2013 or 2014 cohort's first year of participation (-$13 per beneficiary [95% CI, -$33 to $6]; P = .19; and $4 per beneficiary [95% CI, -$15 to $24]; P = .66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality. Conclusions and Relevance: Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.
[Mh] Termos MeSH primário: Planos de Pagamento por Serviço Prestado/estatística & dados numéricos
Medicare
Alta do Paciente
Readmissão do Paciente
Qualidade da Assistência à Saúde
Cuidados Semi-Intensivos
[Mh] Termos MeSH secundário: Organizações de Assistência Responsáveis/métodos
Idoso
Redução de Custos
Avaliação da Deficiência
Feminino
Gastos em Saúde/estatística & dados numéricos
Seres Humanos
Masculino
Medicare/economia
Medicare/estatística & dados numéricos
Alta do Paciente/normas
Alta do Paciente/estatística & dados numéricos
Readmissão do Paciente/normas
Readmissão do Paciente/estatística & dados numéricos
Qualidade da Assistência à Saúde/organização & administração
Qualidade da Assistência à Saúde/normas
Distribuição Aleatória
Instituições de Cuidados Especializados de Enfermagem/organização & administração
Cuidados Semi-Intensivos/economia
Cuidados Semi-Intensivos/métodos
Cuidados Semi-Intensivos/organização & administração
Estados Unidos/epidemiologia
[Pt] Tipo de publicação:COMPARATIVE STUDY; JOURNAL ARTICLE
[Em] Mês de entrada:1706
[Cu] Atualização por classe:170622
[Lr] Data última revisão:
170622
[Sb] Subgrupo de revista:AIM; IM
[Da] Data de entrada para processamento:170214
[St] Status:MEDLINE
[do] DOI:10.1001/jamainternmed.2016.9115



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