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Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery.

ABSTRACT: BACKGROUND:Accountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients. OBJECTIVE:To determine whether such informal clinical integration relates to a health system's performance in an ACO. RESEARCH DESIGN:We analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physicians delivered care to them, we aggregated across episodes to construct physician networks for each health system. We used network analysis to measure each system's level of informal clinical integration (defined by cross-specialty ties). We fit regression models to examine the association between a health system's CABG mortality rate and ACO participation, conditional on informal clinical integration. SUBJECTS:Beneficiaries age 66 and older undergoing CABG. MEASURES:Ninety-day CABG mortality. RESULTS:Over the study period, 3385 beneficiaries were treated in 161 ACO-participating health systems. The remaining 49,854 were treated in 875 nonparticipating systems or one of the 161 ACO-participating systems before the ACO start date. ACO systems with higher levels of informal clinical integration had lower CABG mortality rates than nonparticipating ones (2.8% versus 5.5%; P<0.01); however, there was no difference based on ACO participation for health systems with lower to relatively moderate informal clinical integration. Regression results corroborate this finding (coefficient for interaction between ACO participation and informal clinical integration level is -0.25; P=0.01). CONCLUSIONS:Formal clinical integration through ACO participation may be insufficient to improve outcomes. Health systems with higher informal clinical integration may benefit more from ACO participation.

SUBMITTER: Kim D

PROVIDER: S-EPMC6421077 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

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Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery.

Kim Dennie D Funk Russell J RJ Yan Phyllis P Nallamothu Brahmajee K BK Zaheer Aks A Hollingsworth John M JM

Medical care 20190301 3

<h4>Background</h4>Accountable care organizations' (ACOs') focus on formal clinical integration to improve outcomes overlooks actual patterns of provider interactions around shared patients.<h4>Objective</h4>To determine whether such informal clinical integration relates to a health system's performance in an ACO.<h4>Research design</h4>We analyzed national Medicare data (2008-2014), identifying beneficiaries who underwent coronary artery bypass grafting (CABG). After determining which physician ...[more]

PMID: 30629017

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Project description:BACKGROUND:Accountable care organizations (ACOs) were established to improve care and outcomes for beneficiaries requiring highly coordinated, complex care. The objective of this study was to evaluate the association between hospital ACO participation and the outcomes of major surgical oncology procedures. METHODS:This was a retrospective cohort study of Medicare beneficiaries older than 65 years who were undergoing a major surgical resection for colorectal, bladder, esophageal, kidney, liver, ovarian, pancreatic, lung, or prostate cancer from 2011 through 2013. A difference-in-differences analysis was implemented to compare the postimplementation period (January 2013 through December 2013) with the baseline period (January 2011 through December 2012) to assess the impact of hospital ACO participation on 30-day mortality, complications, readmissions, and length of stay (LOS). RESULTS:Among 384,519 patients undergoing major cancer surgery at 106 ACO hospitals and 2561 control hospitals, this study found a 30-day mortality rate of 3.4%, a readmission rate of 12.5%, a complication rate of 43.8%, and a prolonged LOS rate of 10.0% in control hospitals and similar rates in ACO hospitals. Secular trends were noted, with reductions in perioperative adverse events in control hospitals between the baseline and postimplementation periods: mortality (percentage-point reduction, 0.1%; P?=?.19), readmissions (percentage-point reduction, 0.4%; P?=?.001), complications (percentage-point reduction, 1.0%; P?<?.001), and prolonged LOS (percentage-point reduction, 1.1%; P?<?.001). After accounting for these secular trends, this study identified no significant effect of hospital participation in an ACO on the frequency of perioperative outcomes (difference-in-differences estimator P values, .24-.72). CONCLUSIONS:Early hospital participation in the Medicare Shared Savings Program ACO program was not associated with greater reductions in adverse perioperative outcomes for patients undergoing major cancer surgery in comparison with control hospitals. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2739-2746. © 2016 American Cancer Society.

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Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery.

Publications

Informal Clinical Integration in Medicare Accountable Care Organizations and Mortality Following Coronary Artery Bypass Graft Surgery.

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