How CPC+ supported patient care during the COVID-19 pandemic: Lessons for alternative payment models

BACKGROUND

A growing literature documents how primary care practices adapted to the COVID-19 pandemic. We examine a topic that has received less attention-how participants in an advanced alternative payment model perceive the model influenced their ability to meet patients' care needs during the pandemic.

METHODS

Analysis of closed- and open-ended questions from a 2021 survey of 2496 practices participating in the Comprehensive Primary Care Plus (CPC+) model (92% response rate) and a 2021 survey of 993 randomly selected primary care physicians from these practices (55% response rate). Both surveys asked whether respondents agreed or disagreed that they or their practice was "better positioned to meet patients' care needs during the coronavirus pandemic" because of participation in CPC+. Both also included an open-ended question about CPC+'s effects.

RESULTS

Half of practices and one-third of physicians agreed or strongly agreed that participating in CPC+ better positioned them to meet patients' care needs during the pandemic. One in 10 practices and 2 in 10 physicians, disagreed or strongly disagreed, while 4 in 10 practices and slightly more than half of physicians neither agreed nor disagreed (or, for physicians, didn't know). The most commonly identified CPC+ activities that facilitated meeting patient care needs related to practices' work on care management (e.g., risk stratification), access (e.g., telehealth), payment outside of fee-for-service (FFS), and staffing (e.g., supporting care managers).

CONCLUSIONS

Most CPC+ practices and physicians were positive or neutral about participating in CPC+ in the context of COVID-19, indicating more benefit than risk to payment alternatives to FFS.

Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis

BACKGROUND

Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants.

OBJECTIVE

This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery.

STUDY DESIGN

A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies.

RESULTS

Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy.

CONCLUSION

The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions

IMPORTANCE

Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care.

OBJECTIVE

To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions.

DESIGN, SETTING, AND PARTICIPANTS

This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020.

MAIN OUTCOMES AND MEASURES

Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders.

RESULTS

Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions.

CONCLUSIONS AND RELEVANCE

Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Between-Community Low-Income Status and Inclusion in Mandatory Bundled Payments in Medicare's Comprehensive Care for Joint Replacement Model

This cohort study examines whether communities in Medicare’s Comprehensive Care for Joint Replacement (CJR) Model are representative of others nationwide with respect to residents’ socioeconomic status.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE

We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model.

DATA SOURCES

We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas.

STUDY DESIGN

We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR.

PRINCIPAL FINDINGS

Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant.

CONCLUSIONS

When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Bridging the gap: an economic case study of the impact and cost effectiveness of comprehensive healthcare intermediaries in rural Mexico

BACKGROUND

In rural settings where patients face significant structural barriers to accessing healthcare services, the formal existence of government-provided health coverage does not necessarily translate to meaningful care delivery. This paper analyses the effectiveness of an innovative approach to overcome these barriers, the Right to Health Care programme offered by Compañeros en Salud in Chiapas, Mexico. This programme provides comprehensive free coverage of all additional direct and indirect medical costs as well as accompaniment through the medical system. Over 550 patients had participated from 2013 until November 2018.

METHODS

Focusing on ten of the most frequently treated conditions, including hernias, cataracts and congenital heart defects, we performed a retrospective case study analysis of the quality-adjusted life years (QALYs) gained from treatment and the cost per QALY for 69 patients. This analysis used disability weights and uncertainty intervals from the Global Burden of Disease study and organisational micro-costing data for each patient. Each patient was compared to their own hypothetical counterfactual health outcome had they not received the secondary and tertiary care required for the specific condition. A mixed methods approach is used to establish this counterfactual baseline, drawing on pre-intervention observations, qualitative interviews and established literature precedent.

RESULTS

The programme was found to deliver an average of 14.4 additional QALYs (95% uncertainty interval 12.4-15.8) without time discounting. The mean cost per QALY over these conditions was $388 USD (95% UI $262-588) at purchasing power parity.

CONCLUSIONS

These numbers compare favourably with studies of other health services and international cost per QALY guidelines. They reflect the on-treatment effect for the ten conditions analysed and are presented as a case study indicative of the promise of healthcare intermediaries rather than a definitive assessment of cost-effectiveness. Nonetheless, these results show the potential feasibility and cost effectiveness of a more comprehensive approach to healthcare provision in a resource-limited rural setting.

TRIAL REGISTRATION

This study involves economic analysis of a programme facilitating access to public healthcare services. Thus, there was no associated clinical trial to be registered.

Association of Organizational Factors and Physician Practices' Participation in Alternative Payment Models

Importance

Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation.

Objective

To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices.

Design, Setting, and Participants

A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019.

Exposures

Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors.

Main Outcomes and Measures

Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts.

Results

A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation.

Conclusions and Relevance

Greater APM participation appears to be supported by integration and system ownership.

Effect of Comprehensive Care Coordination on Medicaid Expenditures Compared With Usual Care Among Children and Youth With Chronic Disease: A Randomized Clinical Trial

IMPORTANCE

Medicaid spending on children and young adults with chronic disease could be decreased through care coordination programs by reducing unnecessary hospital and emergency care.

OBJECTIVE

To assess whether a comprehensive care coordination program reduces Medicaid expenditures by decreasing hospital and emergency department (ED) utilization.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included 6259 children and young adults with chronic disease who received public insurance through Illinois Medicaid. In April 2016, eligible youth were randomized to receive comprehensive care coordination through the Coordinated Healthcare for Complex Kids (CHECK) program (n = 3126) or usual care (n = 3119) to measure the effect of the CHECK program on Medicaid expenditures and health care utilization using a difference-in-differences (DID) approach. Data were collected from May 1, 2014, to April 30, 2017, and analyzed in May 2018.

INTERVENTIONS

Care coordination, mental health care, education, and social support were provided to CHECK participants and their family members. Services were tailored based on family and participant need.

MAIN OUTCOMES AND MEASURES

Mean annual Medicaid expenditures, mean annual health care utilization by category (ED and inpatient), and chronic disease type and risk level.

RESULTS

A total of 6259 participants (mean [SD] age, 11.3 [6.4] years; 2918 [46.6%] female; 2594 [41.4%] with medium and high risk) were randomized. Following the exclusion of 14 outliers, 6245 participants were analyzed. The mean (SD) annual Medicaid expenditure before the intervention was $1633 ($4006) for the intervention group and $1703 ($4466) for the usual care group, which decreased to a mean (SD) of $1341 ($3004) and $1413 ($3785), respectively, after the intervention (DID, -$1; 95% CI, -$199 to $196; P = .99). The mean (SD) inpatient utilization before the intervention was 63.0 (344.4) per 1000 person-years (PYs) for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention (DID, 2.0; 95% CI, -17.9 to 21.8; P = .85). Among participants with asthma, those in the intervention group had a greater mean (SD) decrease in ED utilization compared with usual care, but the difference was not significant (-225.9 [65.3] vs -104.5 [80.0] visits per 1000 PY; DID, -121.5; 95% CI, -268.9 to 26.0; P = .11). Similarly, enrolled participants with sickle cell disease had a smaller but not significant mean (SD) increase in ED utilization compared with usual care (583.3 [839.0] vs 3761.9 [4611.2] visits per 1000 PYs; DID, -3178.6; 95% CI, -10 724.3 to 4367.2; P = .41).

CONCLUSIONS AND RELEVANCE

Overall Medicaid expenditures and health care utilization (hospital and ED) decreased similarly for both CHECK participants and the usual care group.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04057521.

Care Transformation Collaborative of Rhode Island: Building a Strong Foundation for Comprehensive, High-Quality Affordable Care

As the Patient Centered Medical Home (PCMH) model has evolved nationally and in Rhode Island, there has been increased recognition that PCMH has not been sufficient to achieve desired cost and quality goals. In this article, we describe the evolving concept of "comprehensive primary care" in Rhode Island, which includes addressing the behavioral health and social determinants of health (SDOH) needs of patients. These needs are identified through systematic screening and dedicated care management and care coordination for patients who present with complex needs.

Program of All-Inclusive Care for the Elderly (PACE): Integrating Health and Social Care Since 1973

According to the Centers for Medicare & Medicaid Services (CMS), the future of older adult care in the United States has arrived in a provider-sponsored health plan model that integrates medical, behavioral, and social care for frail elders. This approach gives the provider complete control over patient outcomes and total cost of care and enables participants to live safely in the community - rather than a nursing home - for an extra four years, on average. This article reviews the Program of All-inclusive Care for the Elderly (PACE) model, whose roots go back to the 1970s in California, and offers case studies on two PACE-RI participants with chronic healthcare needs. In both examples, the patients reduced hospitalizations and increased mental and physical health, all while alleviating caregiver stress. With the older population slated to double by 2060, the time has come to expand PACE to more people. A few years ago, the acting administrator of the Centers for Medicare & Medicaid Services (CMS) said he was "glimpsing into our future" when he visited a provider-sponsored health plan that integrated medical, behavioral, and social care for frail elders, allowing them to remain in the community rather than live in a nursing home.[1] This approach to aging services successfully braided Medicare and Medicaid funding and gave the provider complete control over patient outcomes and total cost of care over a significant period - the key elements to delivering "value-based care." What is noteworthy is that this program of the "future" has been in Rhode Island since 2005 and in other parts of the country since 1973! It helps its medically complex participants live at home for an extra four years on average and retain a much higher quality of life, all while controlling associated costs for the government through capitated payment arrangements.[5] The program is called PACE - short for Program of All-inclusive Care for the Elderly - and it is a comprehensive and community-based model of care that coordinates medical, behavioral, and social services for individuals ages fifty-five and older who have high care needs but can remain safely in the community. PACE is currently offered in 31 states.[2] The model is backed by the National PACE Association and serves 50,000 seniors in 126 sponsoring organizations at 260 PACE centers across the country. While PACE has already had some success at scaling its integrated services, emerging demographics and heightened outreach poise the program for significant growth.

The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review

Integrated care is increasingly promoted as an effective and cost-effective way to organise care for community-dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost-effectiveness of preventive, integrated care for community-dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost-effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk-of-bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom-reported outcomes such as well-being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost-effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost-effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.

Value of Comprehensive HCV Treatment among Vulnerable, High-Risk Populations

OBJECTIVES

The objective of this study was to explore the trade-offs society and payers make when expanding treatment access to patients with chronic hepatitis C virus (HCV) infection in early stages of disease as well as to vulnerable, high-risk populations, such as people who inject drugs (PWID) and HIV-infected men who have sex with men (MSM-HIV).

METHODS

A discrete time Markov model simulated HCV progression and treatment over 20 years. Population cohorts were defined by behaviors that influence the risk of HCV exposure: PWID, MSM-HIV, an overlap cohort of individuals who are both PWID and MSM-HIV, and all other adults. Six different treatment scenarios were modeled, with varying degrees of access to treatment at different fibrosis stages and to different risk cohorts. Benefits were measured as quality-adjusted life-years and a $150,000/quality-adjusted life-year valuation was used to assess social benefits.

RESULTS

Compared with limiting treatment to METAVIR fibrosis stages F3 or F4 and excluding PWID, expanding treatment to patients in all fibrosis stages and including PWID reduces cumulative new infections by 55% over a 20-year horizon and reduces the prevalence of HCV by 93%. We find that treating all HCV-infected individuals is cost saving and net social benefits are over $500 billion greater compared with limiting treatment. Including PWID in treatment access saves 12,900 to 41,200 lives.

CONCLUSIONS

Increased access to treatment brings substantial value to society and over the long-term reduces costs for payers, as the benefits accrued from long-term reduction in prevalent and incident cases, mortality, and medical costs outweigh the cost of treatment.

Primary or specialist medical care: Which is more equitable? A policy brief

BACKGROUND

Equity in health and equitable access to healthcare has been at the core of health policy in India. The key policy challenge has been how to make that possible? Various health insurance schemes such as the Rashtriya Swasthya Bima Yojana and Arogyasri seek to improve poor people's access to specialist medical care in the public and private sectors. On the other hand, access to primary medical care has been left to the supply side interventions.

METHODS

We did a focused review of evidence on equity aspects of primary medical care versus specialist medical care. We selected relevant publications from the Cochrane Library, PubMed and Google Scholar searches and articles snowballing out of them.

RESULTS

Higher primary care physician-to-population ratio is invariably associated with better health outcomes. Primary care may partly protect the poor from adverse effects of income inequality on health status. On the other hand, populations do not necessarily benefit from an overabundance of specialists in a geographical area.

CONCLUSIONS

Three key policy lessons emerge from this review. First, states should strengthen primary medical care by upgrading health centres. Second, a family health protection plan should be introduced as a demand side intervention to deliver primary care through health centres, non-profit and for-profit clinics. Third, postgraduate courses in family medicine should be introduced for a balanced development of the specialty of primary care pari passu other specialties.

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). Final rule

This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

Comprehensive Corporate Social Responsibility Health Programs: Providing Quality, Affordable and Accessible Healthcare for Financially - Chal- lenged Patients (Private Tertiary Hospital Setting)

In 2012 the Manila Doctors Hospital became the first hospital in the Philippines to launch and commit to a Social Vision. Since then, this Social Vision has served as a guide for good governance and a blueprint for its Corporate Social Responsibility (CSR) programs focusing on health, environment and gender. The goal of the Manila Doctors comprehensive CSR health program is to render the fundamental right to health care available to marginalized patients. Through our CSR programs, more than 20,000 financially challenged patients gain access to quality medical services annually. This directly contributed to the country's health development agenda 2016-2020 of achieving the health related SDG Targets of Financial Risk Protection, Better Health Outcomes and Responsiveness.

Donor Agencies' Involvement in Reproductive Health: Saying One Thing and Doing Another?

The debates about what services constitute reproductive health, how these services should be organized, managed, and delivered, and what the role of donor agencies' support should be mirror the long-standing debates on how best to implement primary health care. After briefly reviewing the development of the discourse on primary health care and reproductive health, the authors present results of qualitative research in Ghana, Kenya, and Zambia that indicate a range of factors influencing and explaining the way donors operate in these countries and consider the implications of these results for the delivery of comprehensive reproductive health services. These findings are compared with South Africa, a country with limited donor activity. In the light of the complex interplay of factors, the authors suggest that donors' words and actions frequently do not correlate. Conclusions are drawn as to the potential for donor support for integrated reproductive health service delivery in sub-Saharan Africa, drawing on the research to provide lessons and a reappraisal of the role of donors in health sector aid.

Comprehensive Care for Joint Replacement (CJR) Bundle Expense in Perioperative Pain Management

The implementaion of the Comprehensive Care for Joint Replacement (CJR) model has necessitated value-focused care for a 90-day period. Pain management in joint arthroplasty therefore represents a focused opportunity to achieve lasting change in the delivery of care. To be successful, orthopedic surgeons must integrate approaches that take into account administration route and therapy duration, and various combinations thereof, to achieve improved longer term outcomes for joint arthroplasty patients. In addition, pain management choices must be based on value and not on simple costs, as patient satisfaction scores affect CJR repayments. While the postdischarge time period poses the highest risk, improved collaboration with post-acute care providers, such as hospitalists, pharmacists, and rehabilitation facilities will be crucial to addressing patient comorbidities and ensuring optimal outcomes post-surgery. Furthermore, multimodal pain management strategies associated with optimal pain control and shorter hospital stays are valuable in achieving improved outcome and financial metrics.

Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule

This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.

Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial

BACKGROUND

Most patients with hip fractures are characterised by older age (>70 years), frailty, and functional deterioration, and their long-term outcomes are poor with increased costs. We compared the effectiveness and cost-effectiveness of giving these patients comprehensive geriatric care in a dedicated geriatric ward versus the usual orthopaedic care.

METHODS

We did a prospective, single-centre, randomised, parallel-group, controlled trial. Between April 18, 2008, and Dec 30, 2010, we randomly assigned home-dwelling patients with hip-fractures aged 70 years or older who were able to walk 10 m before their fracture, to either comprehensive geriatric care or orthopaedic care in the emergency department, to achieve the required sample of 400 patients. Randomisation was achieved via a web-based, computer-generated, block method with unknown block sizes. The primary outcome, analysed by intention to treat, was mobility measured with the Short Physical Performance Battery (SPPB) 4 months after surgery for the fracture. The type of treatment was not concealed from the patients or staff delivering the care, and assessors were only partly masked to the treatment during follow-up. This trial is registered with ClinicalTrials.gov, number NCT00667914.

FINDINGS

We assessed 1077 patients for eligibility, and excluded 680, mainly for not meeting the inclusion criteria such as living in a nursing home or being aged less than 70 years. Of the remaining patients, we randomly assigned 198 to comprehensive geriatric care and 199 to orthopaedic care. At 4 months, 174 patients remained in the comprehensive geriatric care group and 170 in the orthopaedic care group; the main reason for dropout was death. Mean SPPB scores at 4 months were 5·12 (SE 0·20) for comprehensive geriatric care and 4·38 (SE 0·20) for orthopaedic care (between-group difference 0·74, 95% CI 0·18-1·30, p=0·010).

INTERPRETATION

Immediate admission of patients aged 70 years or more with a hip fracture to comprehensive geriatric care in a dedicated ward improved mobility at 4 months, compared with the usual orthopaedic care. The results suggest that the treatment of older patients with hip fractures should be organised as orthogeriatric care.

FUNDING

Norwegian Research Council, Central Norway Regional Health Authority, St Olav Hospital Trust and Fund for Research and Innovation, Liaison Committee between Central Norway Regional Health Authority and the Norwegian University of Science and Technology, the Department of Neuroscience at the Norwegian University of Science and Technology, Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology (SINTEF), and the Municipality of Trondheim.

What are FQHCs and how do they affect dental services?

Federally Qualified Health Centers serve, on a "cost-to-provide-care basis," low-income and other patients who cannot use private pay facilities. This is a safety-net care system that is much more comprehensive and less expensive than emergency room visits. The existence of an FQHC in a community partially removes the pressure on fee-for-service providers to make arrangements for treating dentally disadvantaged individuals. Increases in federal spending for dental services have recently outpaced declines in out-of-pocket private pay spending and sluggish improvements in insurance coverage.

Financial planning on a comprehensive scale

Hospitals and health systems that wish to explore the shift to comprehensive care management should: Assess the investments in infrastructure necessary to support comprehensive care management, Gauge the financial implications and set quality and financial goals, Monitor performance using metrics such as patient satisfaction, avoidable admissions, out-of-group referrals, and average length of stay.