Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis

BackgroundUpcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care.MethodsWe performed a cross-sectional analysis of visits in the United States' National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use.ResultsAbout 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics.ConclusionsPractices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models

Gordonia araii Infection Associated with an Orthopedic Device and Review of the Literature on Medical Device-Associated Gordonia Infections▿

Gordonia infections in humans are rare and usually affect immunocompromised patients. We present the first case of Gordonia araii infection associated with a medical device in an immunocompetent patient. Sequencing was required for conclusive identification. We compared our case to the 16 Gordonia species-associated medical device infections reported to date

Hearing Loss Among Older Adults With Heart Failure in the United States: Data From the National Health and Nutrition Examination Survey

Hearing loss is common among older adults in the United States1 and is associated with coronary heart disease and its risk factors.2 Yet, the prevalence of hearing loss among adults with heart failure (HF) has not been well described.Heart failure is a chronic, incurable disease and is the leading cause of hospitalization among older adults in the United States. To mitigate disease progression, patients are asked to take multiple medications and make lifestyle changes.3 Given the high degree of self-care that HF imposes, it is imperative that patients can hear physician recommendations. Herein, we examined the prevalence and correlates of hearing loss among older adults with and without HF in the United States

Differences in Risk of Sudden Cardiac Death Between Blacks and Whites

BackgroundPrior studies have consistently demonstrated that blacks have an approximate 2-fold higher incidence of sudden cardiac death (SCD) than whites; however, these analyses have lacked individual-level sociodemographic, medical comorbidity, and behavioral health data.ObjectivesThe purpose of this study was to evaluate whether racial differences in SCD incidence are attributable to differences in the prevalence of risk factors or rather to underlying susceptibility to fatal arrhythmias.MethodsThe Reasons for Geographic and Racial Differences in Stroke study is a prospective, population-based cohort of adults from across the United States. Associations between race and SCD defined per National Heart, Lung, and Blood Institute criteria were assessed.ResultsAmong 22,507 participants (9,416 blacks and 13,091 whites) without a history of clinical cardiovascular disease, there were 174 SCD events (67 whites and 107 blacks) over a median follow-up of 6.1 years (interquartile range: 4.6 to 7.3 years). The age-adjusted SCD incidence rate (per 1,000 person-years) was higher in blacks (1.8; 95% confidence interval [CI]: 1.4 to 2.2) compared with whites (0.7; 95% CI: 0.6 to 0.9), with an unadjusted hazard ratio of 2.35; 95% CI: 1.74 to 3.20. The association of black race with SCD risk remained significant after adjustment for sociodemographics, comorbidities, behavioral measures of health, intervening cardiovascular events, and competing risks of non-SCD mortality (hazard ratio: 1.97; 95% CI: 1.39 to 2.77).ConclusionsIn a large biracial population of adults without a history of cardiovascular disease, SCD rates were significantly higher in blacks as compared with whites. These racial differences were not fully explained by demographics, adverse socioeconomic measures, cardiovascular risk factors, and behavioral measures of health

Outcomes after antiretroviral therapy during the expansion of HIV services in Haiti

Background: We report patient outcomes after antiretroviral therapy (ART) initiation in a network of HIV facilities in Haiti, including temporal trends and differences across clinics, during the expansion of HIV services in the country. Methods: We assessed outcomes at 12 months after ART initiation (baseline) using routinely collected data on adults (≥15 years) in 11 HIV facilities from July 2007-December 2013. Outcomes include death (ascertained from medical records), lost to follow-up (LTF) defined as no visit > 365 days from ART initiation, and retention defined as being alive and attending care ≥ 365 days from ART initiation. Outcomes were compared across calendar year of ART initiation and across facilities. Risk factors for death and LTF were assessed using Cox proportional hazards and competing risk regression models. Results: Cumulatively, 9,718 adults initiated ART with median age 37 years (IQR 30–46). Median CD4 count was 254 cells/uL (IQR 139–350). Twelve months after ART initiation, 4.4% (95% CI 4.0–4.8) of patients died, 21.7% (95% CI 20.9–22.6) were LTF, and 73.9% (95% CI 73.0–74.8) were retained in care. Twelve-month mortality decreased from 13.8% among adults who started ART in 2007 to 4.4% in 2013 (p<0.001). Twelve-month LTF after ART start was 29.2% in 2007, 18.7% in 2008, and increased to 30.1% in 2013 (p<0.001). Overall, twelve-month retention after ART start did not change over time but varied widely across facilities from 61.1% to 86.5%. Conclusion: Expansion of HIV services across Haiti has been successful with increasing numbers of patients initiating ART and decreasing twelve-month mortality rates. However, overall retention has not improved, despite differences across facilities, suggesting additional strategies to improve engagement in care are needed

Map of included HIV facilities (N = 11) in Haiti.

<p>Map of included HIV facilities (N = 11) in Haiti.</p

Patient and facility characteristics at time of antiretroviral therapy initiation in GHESKIO-supported HIV facilities in Haiti from July 2007-December 2013 (N = 9,718).

<p>Patient and facility characteristics at time of antiretroviral therapy initiation in GHESKIO-supported HIV facilities in Haiti from July 2007-December 2013 (N = 9,718).</p

Death, lost to follow-up and retention at 12-months after ART initiation among adults initiating ART in GHESKIO-MSPP facilities in Haiti from 2007 to 2013.

<p>Median point estimates are plotted with 95% Confidence Interval bars.</p

Patient and facility characteristics associated with death and lost to follow-up at 12 months after antiretroviral initiation.

<p>Patient and facility characteristics associated with death and lost to follow-up at 12 months after antiretroviral initiation.</p

Patient characteristics and outcomes of adults initiating antiretroviral therapy by calendar year of initiation and by HIV facility.

<p>Patient characteristics and outcomes of adults initiating antiretroviral therapy by calendar year of initiation and by HIV facility.</p