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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.

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. 1 , 2 Randomized, controlled trials comparing endovascular repair with open repair generally have shown a perioperative benefit of endovascular repair over open repair. 3 – 5 Long-term survival, however, is similar with the two approaches. 6 – 9 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 . . .

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.

It has been widely assumed that better management and coordination of care for chronic conditions and high-risk patients would be the leading mechanisms for achieving savings in accountable care organizations (ACOs), specifically by reducing acute care needs through enhanced outpatient and preventive care. We examined the extent to which changes in spending and hospitalizations for ACO patients in the Medicare Shared Savings Program (MSSP) have been consistent with this expectation. By 2014, participation in the MSSP was associated with significant reductions in total Medicare fee-for-service spending for ACO patients but with proportionately smaller reductions in hospitalizations and some increases in hospitalizations for ambulatory care-sensitive conditions. In addition, spending reductions were not clearly concentrated among high-risk patients: Reductions for those patients accounted for only 38 percent of the total reduction among ACOs entering the MSSP in 2012, and reductions among 2013 MSSP entrants were almost entirely concentrated among lower-risk patients. These findings suggest that, on average, care coordination and management efforts focused on ambulatory care-sensitive conditions and high-risk patients have not been the major drivers of early savings in the MSSP.

Benzodiazepines are implicated in a growing number of overdose-related deaths. To quantify patterns in outpatient benzodiazepine prescribing and to compare them across specialties and indications. This serial cross-sectional study (January 1, 2003, through December 31, 2015) used nationally representative National Ambulatory Medical Care Survey data. The yearly population-based sample of outpatient visits among adults, ranging from 20 884 visits in 2003 (representing 737 million visits) to 24 273 visits in 2015 (representing 841 million visits) was analyzed. Prescribing patterns were examined by specialty and indication and used to calculate the annual coprescribing rate of benzodiazepines with other sedating medications. Data were analyzed from July 1, 2017, through November 30, 2018. Annual benzodiazepine visit rate. Among the 386 457 ambulatory care visits from 2003 through 2015, a total of 919 benzodiazepine visits occurred in 2003 and 1672 in 2015, nationally representing 27.6 million and 62.6 million visits, respectively. The benzodiazepine visit rate doubled from 3.8% (95% CI, 3.2%-4.4%) to 7.4% (95% CI, 6.4%-8.6%; P < .001) of visits. Visits to primary care physicians accounted for approximately half of all benzodiazepine visits (52.3% [95% CI, 50.0%-54.6%]). The benzodiazepine visit rate did not change among visits to psychiatrists (29.6% [95% CI, 23.3%-36.7%] in 2003 to 30.2% [95% CI, 25.6%-35.2%] in 2015; P = .90), but increased among all other physicians, including primary care physicians (3.6% [95% CI, 2.9%-4.4%] to 7.5% [95% CI, 6.0%-9.5%]; P < .001). The benzodiazepine visit rate increased slightly for anxiety and depression (26.6% [95% CI, 22.6%-31.0%] to 33.5% [95% CI, 28.8%-38.6%]; P = .003) and neurologic conditions (6.8% [95% CI, 4.8%-9.5%] to 8.7% [95% CI, 6.2%-12.1%]; P < .001), but more so for back and/or chronic pain (3.6% [95% CI, 2.6%-4.9%] to 8.5% [95% CI, 6.0%-11.9%]; P < .001) and other conditions (1.8% [95% CI, 1.4%-2.2%] to 4.4% [95% CI, 3.7%-5.2%]; P < .001); use did not change for insomnia (26.9% [95% CI, 19.3%-36.0%] to 25.6% [95% CI, 15.3%-39.6%]; P = .72). The coprescribing rate of benzodiazepines with opioids quadrupled from 0.5% (95% CI, 0.3%-0.7%) in 2003 to 2.0% (95% CI, 1.4%-2.7%) in 2015 (P < .001); the coprescribing rate with other sedating medications doubled from 0.7% (95% CI, 0.5%-0.9%) to 1.5% (95% CI, 1.1%-1.9%) (P < .001). The outpatient use of benzodiazepines has increased substantially. In light of increasing rates of overdose deaths involving benzodiazepines, understanding and addressing prescribing patterns may help curb the growing use of benzodiazepines.

Background There are major concerns about the sustainability of the US primary care (PC) system. Objective We use similar data from the USA and Australia on adult visits to primary care physicians to examine how primary care service delivery and content in the countries have changed since the year 2001. Design/Setting/Participants Longitudinal analyses of nationally representative data collected in a similar manner on outpatient visits to PC in the USA (National Ambulatory Medical Care Survey, NAMCS) and Australia (Bettering the Evaluation and Care of Health, BEACH), 2001–2016. Main Measures For each visit, we ascertained the problems/diagnoses managed; the length of the visit in minutes; what medications were recorded; whether counseling, advice, or education was provided; the rate of imaging and diagnostics tests; the laboratory tests ordered; and whether the visit resulted in a referral to another physician. Key Results Between 2001 and 2016, there were 128,770 encounters with adult patients in NAMCS and 1,338,963 in BEACH. In the USA, the proportion of encounters with 3 or more problems managed increased from 28.7 to 54.8% whereas Australia started at a lower proportion (10.6%) and increased to just 14.1%. Visit times in the USA increased from 17.2 min in 2001 to 22.9 min in 2016 as compared to 14.4 min increasing to 15.2 in Australia. There were significantly more medications recorded over time in NAMCS than BEACH (2.02 in 2001 to 3.32 in 2016, USA, and 1.10 and 1.04, Australia), and US encounters resulted in imaging studies, lab tests, or referrals with relatively increasing frequency. Conclusion Relative to Australia, PC visits in the USA increasingly entail more complexity with visits that have grown comparatively longer over time, with more problems addressed, and with more content.

The hospital industry has consolidated substantially during the past two decades and at an accelerated pace since 2010. Multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, -0.17 SD; 95% confidence interval [CI], -0.26 to -0.07; P = 0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (-0.10 percentage points; 95% CI, -0.53 to 0.34; P = 0.72) or in 30-day mortality (-0.03 percentage points; 95% CI, -0.20 to 0.14; P = 0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P = 0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive. (Funded by the Agency for Healthcare Research and Quality.).

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.

A high prevalence of mental health diagnoses in adults alongside ongoing shortages of mental health specialists and expansion of the patient-centered medical home have increased the involvement of primary care clinicians in treating mental health concerns. Using nationally representative serial cross-sectional data from the 2006-18 National Ambulatory Medical care surveys regarding visits to outpatient primary care physicians by patients ages eighteen and older, we sought to characterize temporal trends in primary care visits addressing a mental health concern. Based on a sample of 109,898 visits representing 3,891,233,060 weighted visits, we found that the proportion of visits that addressed mental health concerns increased from 10.7 percent of visits in 2006-07 to 15.9 percent by 2016 and 2018. Black patients were 40 percent less likely than White patients to have a mental health concern addressed during a primary care visit, and Hispanic patients were 40 percent less likely than non-Hispanic patients to have a mental health concern addressed during a primary care visit. These findings emphasize the need for payment and billing approaches (that is, value-based care models and billing codes for integrated behavioral health) as well as organizational designs and supports (that is, colocated therapy or psychiatry providers, availability of e-consultation, and longer visits) that enable primary care physicians to adequately address mental health needs.