Journal of the American Geriatrics Society
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Multicenter Study
How Do Frail Medicare Beneficiaries Fare Under Bundled Payments?
Bundled payments are an alternative payment model in which a hospital takes accountability for the costs of a 90-day episode of care. Such models are meant to improve care through better coordination across care settings, but could have adverse consequences for frail adults if they lead to inappropriate cuts in necessary post-acute care. ⋯ While frail patients had higher costs and worse outcomes in general, there was no evidence of changes in access or worsening clinical outcomes in BPCI hospitals for frail patients relative to the nonfrail in hospitals' first year of participation in the program. These findings may be reassuring for policy makers and clinical leaders. J Am Geriatr Soc 67:2245-2253, 2019.
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Multicenter Study Observational Study
Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations.
To compare aggressiveness of end-of-life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration. ⋯ Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non-ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961-968, 2019.
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Randomized Controlled Trial Multicenter Study Pragmatic Clinical Trial
Pharmacological Management of Delirium in the Intensive Care Unit: A Randomized Pragmatic Clinical Trial.
Delirium in the intensive care units (ICUs) is prevalent, with both delirium duration and delirium severity associated with adverse outcomes. We designed a pragmatic trial to test the efficacy of a pharmacological management of delirium (PMD) bundle in improving delirium/coma-free days and reducing delirium severity among ICU patients. ⋯ Implementing the PMD bundle in the ICU did not reduce delirium duration or severity among critically ill patients.
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Multicenter Study
Post-Acute Care After Joint Replacement in Medicare's Bundled Payments for Care Improvement Initiative.
Bundled payments, in which services provided around a care episode are linked together, are being tested under Medicare's Bundled Payments for Care Improvement (BPCI) program. Reducing post-acute care (PAC) is critical under bundled payment, but little is known about whether this is done through provider selection or consolidation, and whether particular patterns of changes in PAC are associated with success under the program. ⋯ Reductions in spending under BPCI were driven by a shift from higher- to lower-cost discharge settings, and by shortening the duration of institutional PAC. Hospitals that reduced payments the most had the highest spending at baseline. J Am Geriatr Soc 67:1027-1035, 2019.
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Randomized Controlled Trial Multicenter Study
Deprescribing in the Pharmacologic Management of Delirium: A Randomized Trial in the Intensive Care Unit.
Benzodiazepines and anticholinergics are risk factors for delirium in the intensive care unit (ICU). We tested the impact of a deprescribing intervention on short-term delirium outcomes. ⋯ When added to state-of-the-art clinical services, this deprescribing intervention had no impact on medication use in ICU participants. Given the age of the population, results of clinical outcomes may not be easily extrapolated to older adults. Nonetheless, improved approaches for deprescribing or preventing anticholinergics and benzodiazepines should be developed to determine the impact on delirium outcomes. J Am Geriatr Soc 67:695-702, 2019.