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IMPORTANCEIn 2014, Maryland initiated the global budget revenue (GBR) model, placing caps on total hospital expenditures across all care sites. The GBR program aims to reduce unnecessary utilization while maintaining or improving care quality. To date, there has been limited examination of program effects on cancer care. OBJECTIVE To compare changes in spending, clinical outcomes, and acute care utilization through 4 years of the GBR program among Medicare beneficiaries who undergo cancer-directed surgery in Maryland vs matched control states.DESIGN, SETTING, AND PARTICIPANTS Drawing from a matched pool of hospitals in Maryland (n = 35) and 24 control states with a similar timing of Medicaid expansion (n = 101), we identified Medicare beneficiaries from Maryland and control states who underwent any cancer-directed surgery from 2011 through 2018. Using difference-in-differences analysis, we compared changes in outcomes from before (2011)(2012)(2013) to after (2015)(2016)(2017)(2018) GBR implementation between patients treated in Maryland and control states. We also performed a subgroup analysis among patients who underwent major surgical procedures that are usually performed in the inpatient setting (cystectomy, esophagectomy, gastrectomy, colorectal resection, nephrectomy, pancreatectomy, and lung resection). MAIN OUTCOMES AND MEASURESThirty-day episode spending, mortality, readmissions, and emergency department (ED) visits. RESULTSRelative to Medicare beneficiaries undergoing cancer surgery in control states (n = 4737; 3323 [70.1%] female; 571 [12.1%] dual-eligible; mean [SD] age 74.9 [6.5] years), patients in Maryland (n = 20 320; 14 068 [69.2%] female; 1705 [8.4%] dual-eligible; mean [SD] age 74.9 [6.5] years) had a statistically significant reduction of 2.2 percentage points (95% CI, −4.3 to −0.1) in the 30-day readmission rate. We found no statistically significant changes in 30-day spending, mortality, or ED visits. We report no significant results in the subgroup analysis of patients undergoing major surgical procedures.CONCLUSIONS AND RELEVANCE Global budget revenue was not associated with changes in expenditures, ED utilization, or clinical outcomes after cancer-directed surgery through 4 years. There was a modest decline in 30-day readmissions. Specialty-specific definitions of care quality and better alignment across the entire care delivery value chain (ie, physician incentives) may be strategies that could improve delivery of high-value care for beneficiaries undergoing cancer surgery.

ObjectivesTo detect the combined effects of lifestyle factors on work-related burnout (WB) and to analyse the impact of the number of weekend catch-up sleep hours on burnout risk in a medical workplace.DesignCross-sectional study.SettingHospital-based survey in Taiwan.ParticipantsIn total, 2746 participants completed the hospital’s Overload Health Control System questionnaire for the period from the first day of January 2016 to the end of December 2016, with a response rate of 70.5%. The voluntary participants included 358 physicians, 1406 nurses, 367 medical technicians and 615 administrative staff.Primary and secondary outcome measuresAll factors that correlated significantly with WB were entered into a multinomial logistic regression after adjustment for other factors. The dose–response relationship of combined lifestyle factors and catch-up sleep hours associated with WB was explored by logistic regression.ResultsAbnormal meal time (adjusted OR 2.41, 95% CI 1.85 to 3.15), frequently eating out (adjusted OR 1.49, 95% CI 1.12 to 1.97), lack of sleep (adjusted OR 5.13, 95% CI 3.94 to 6.69), no exercise (adjusted OR 1.41, 95% CI 1.10 to 1.81) and >40 work hours (adjusted OR 2.72, 95% CI 2.08–3.57) were independently associated with WB (for high level compared with low level). As the number of risk factors increased (1–5), so did the proportion of high severity of WB (adjusted OR 1.39, 95% CI 0.45 to 4.27, to adjusted OR 32.98, 95% CI 10.78 to 100.87). For those with more than 7 hours’ sleep on workdays, weekend catch-up sleep (≤0/>0 and ≤2/>2 hours) was found to be related to an increase of burnout risk (adjusted OR 4.91, 95% CI 2.24 to 10.75/adjusted OR 4.94, 95% CI 2.54 to 9.63/adjusted OR 6.74, 95% CI 2.94 to 15.46).ConclusionWB in the medical workplace was affected by five unhealthy lifestyle factors, and combinations of these factors were associated with greater severity of WB. Weekend catch-up sleep was correlated with lower burnout risk in those with a short workday sleep duration (less than 7 hours). Clinicians should pay particular attention to medical staff with short sleep duration without weekend catch-up sleep.