No abstract

Background Consequences of antibiotic overuse are substantial, especially among older adults who are more susceptible to adverse reactions. Findings on variation in antibiotic prescribing can target policy efforts to focused areas; however, little is known among older adults. Methods Using 2007–2009 Medicare Part D data (comprising 1.0–1.1 million patients per year), we examined geographic variations in antibiotic use among older adults in 306 Dartmouth hospital-referral regions (HRRs), 50 states and DC, and 4 national regions (South, West, Midwest, and Northeast). We also examined seasonal variation in antibiotic use across four regions. Differences in patient demographics, insurance status, and clinical characteristics were adjusted across regions. Results Substantial geographic and seasonal variation existed across regions, after adjusting for population characteristics. These differences could not be explained by differences in the prevalence of the underlying conditions. For example, the ratios of 75th and 25th percentiles of antibiotic spending are 1.31 across states and 1.32 across hospital-referral regions. The South saw the highest antibiotic use, where 21.4% of patients per quarter used an antibiotic, compared to 17.4% in the West (P<0.01), the lowest region. Regardless of region, the rate of antibiotic use was highest in the first quarter (20.9% in January–March) and lowest in the third quarter (16.9% July–September; P<0.01). Conclusions Areas with high rates of antibiotic use may benefit from targeted programs to reduce unnecessary antibiotic use. Quality improvement programs can set attainable targets using the low-prescribing areas as reference, particularly targeting to older adults.

Although the patient-centered medical home is a well-established model of care for primary care providers, adoption by specialty providers has been relatively limited. Recently, there has been particular interest in developing specialty medical homes in medical oncology because of practice variation, care fragmentation, and high overall costs of care. In 2012, the Center for Medicare and Medicaid Innovation awarded Innovative Oncology Business Solutions a 3-year grant for their Community Oncology Medical Home (COME HOME) program to implement specialty medical homes in seven oncology practices across the country. We report our early experience and lessons learned.Through September 30, 2014, COME HOME has touched 16,353 unique patients through triage encounters, patient education visits, or application of clinical pathways. We describe the COME HOME model and implementation timeline, profile use of key services, and report patient satisfaction. Using feedback from practice sites, we highlight patient-centered innovations and overall lessons learned.COME HOME incorporates best practices care driven by triage and clinical pathways, team-based care, active disease management, enhanced access and care, as well as financial support for the medical home infrastructure. Information technology plays a central role, supporting both delivery of care and performance monitoring. Volume of service use has grown steadily over time, leveling out in second quarter 2014. The program currently averages 1,265 triage encounters, 440 extended hours visits, and 655 patient education encounters per month.COME HOME offers a patient-centered model of care to improve quality and continuity of care.

The Hospital Readmissions Reduction Program (HRRP) initiated by the Affordable Care Act levies financial penalties against hospitals with excess thirty-day Medicare readmissions. We sought to understand the penalty burden over the program's first five years, focusing on characteristics of hospitals that received penalties during all five years, how penalties changed over time, and the relationship between baseline and subsequent performance. More than half of participating hospitals were penalized by the Centers for Medicare and Medicaid Services in all five years of the program. From fiscal years 2013 to 2017, the growth in average penalties was modest, doubling from 0.29 percent to 0.60 percent, despite increasing opportunities for penalization. The penalty burden was greater in hospitals that were urban, major teaching, large, or for-profit and that treated larger shares of Medicare or socioeconomically disadvantaged patients. Surprisingly, hospitals treating greater proportions of medically complex Medicare patients had a lower cumulative penalty burden compared to those treating fewer proportions of these patients. Lastly, we found that hospitals with high baseline penalties in the first year continued to receive significantly higher penalties in subsequent years. For many hospitals, the HRRP leads to persistent penalization and limited capacity to reduce penalty burden. Alternative structures might avoid persistent penalization, while still motivating reductions in hospital readmissions.