Risk Adjustment May Lessen Penalties On Hospitals Treating Complex Cardiac Patients Under Medicare's Bundled Payments

Sex differences in care complexity and cost of cardiac-related procedures as a basis for improving hospital payments systems

In this study, we estimate sex differences in care complexity and cost of cardiac-related procedures in order to demonstrate the importance of sex as a risk adjuster in a hospital payment system. We use individual visit-level data for all adult Israelis who underwent either heart valve surgery (HVS) or coronary artery bypass graft surgery (CABG) during the period 2014-2018 in publicly funded hospitals. We find that women undergoing a cardiac-related procedure are more likely to die during hospitalization, they have longer hospital stays, and overall, they are more likely to be care-complex than men. Furthermore, the cost of the surgery itself is higher for women than for men in the case of HVS (though not CABG), and the cost of the post-operative hospital stay is higher in the case of CABG (though not HVS). It is concluded that sex differences should be considered in the calculation of payment for cardiac-related procedures in order to reduce incentives for selection and reduce unwarranted variation in cardiac-care utilization and medical practice.

Payment systems for dialysis and their effects: a scoping review

BACKGROUND

End stage renal disease (ESRD) is a major health concern and a large drain on healthcare resources. A wide range of payment methods are used for management of ESRD. The main aim of this study is to identify current payment methods for dialysis and their effects.

METHOD

In this scoping review Pubmed, Scopus, and Google Scholar were searched from 2000 until 2021 using appropriate search strategies. Retrieved articles were screened according to predefined inclusion criteria. Data about the study characteristics and study results were extracted by a pre-structured data extraction form; and were analyzed by a thematic analysis approach.

RESULTS

Fifty-nine articles were included, the majority of them were published after 2011 (66%); all of them were from high and upper middle-income countries, especially USA (64% of papers). Fee for services, global budget, capitation (bundled) payments, and pay for performance (P4P) were the main reimbursement methods for dialysis centers; and FFS, salary, and capitation were the main methods to reimburse the nephrologists. Countries have usually used a combination of methods depending on their situations; and their methods have been further developed over time specially from the retrospective payment systems (RPS) towards the prospective payment systems (PPS) and pay for performance methods. The main effects of the RPS were undertreatment of unpaid and inexpensive services, and over treatment of payable services. The main effects of the PPS were cost saving, shifting the service cost outside the bundle, change in quality of care, risk of provider, and modality choice.

CONCLUSION

This study provides useful insights about the current payment systems for dialysis and the effects of each payment system; that might be helpful for improving the quality and efficiency of healthcare.

Neighborhood deprivation and Medicare expenditures for common surgical procedures

INTRODUCTION

The Center of Medicare and Medicaid Services valued based payments for inpatient surgical hospitalizations are adjusted for clinical but not social risk factors. While research has shown that social risk is associated with worse surgical patient outcomes, it is unknown if inpatient surgical episode Medicare payments are affected by social risk factors.

METHODS

Retrospective review of Medicare beneficiaries, age 65-99, undergoing appendectomy, colectomy, hernia repair, or cholecystectomy between 2014 and 2018. Neighborhood deprivation measured by Area Deprivation Index for beneficiary census tract. We evaluated Medicare payments for a total episode of surgical care comprised of index hospitalization, physician fees, post-acute care, and readmission by beneficiary neighborhood deprivation.

RESULTS

A total of 809,059 patients (Women, 56.0%) and mean (SD) age of 75.7 (7.4 years were included. A total of 145,351 beneficiaries lived in the least deprived neighborhoods and 134,188 who lived in the most deprived neighborhoods. Total surgical episode spending was $2654 higher among beneficiaries from the most deprived neighborhoods compared to those from the least after risk adjustment for clinical and hospital factors. These differences were driven in part by higher rates of readmissions (12.9% vs 10.8%, P < 0.001) and post-acute care (67.8% vs. 61.2%, P < 0.001) among beneficiaries living in the most deprived neighborhoods.

CONCLUSION

These findings suggest that value-based payment models with inclusion of social risk adjustment may be needed for surgical cohorts. Moreover, efforts focused on investing in deprived communities may be aligned with surgical quality improvement.

Improving target price calculations in Medicare bundled payment programs

OBJECTIVE

To compare the predictive accuracy of two approaches to target price calculations under Bundled Payments for Care Improvement-Advanced (BPCI-A): the traditional Centers for Medicare and Medicaid Services (CMS) methodology and an empirical Bayes approach designed to mitigate the effects of regression to the mean.

DATA SOURCES

Medicare fee-for-service claims for beneficiaries discharged from acute care hospitals between 2010 and 2016.

STUDY DESIGN

We used data from a baseline period (discharges between January 1, 2010 and September 30, 2013) to predict spending in a performance period (discharges between October 1, 2015 and June 30, 2016). For 23 clinical episode types in BPCI-A, we compared the average prediction error across hospitals associated with each statistical approach. We also calculated an average across all clinical episode types and explored differences by hospital size.

DATA COLLECTION/EXTRACTION METHODS

We used a 20% sample of Medicare claims, excluding hospitals and episode types with small numbers of observations.

PRINCIPAL FINDINGS

The empirical Bayes approach resulted in significantly more accurate episode spending predictions for 19 of 23 clinical episode types. Across all episode types, prediction error averaged $8456 for the CMS approach versus $7521 for the empirical Bayes approach. Greater improvements in accuracy were observed with increasing hospital size.

CONCLUSIONS

CMS should consider using empirical Bayes methods to calculate target prices for BPCI-A.

Evaluation of US Hospital Episode Spending for Acute Inpatient Conditions After the Patient Protection and Affordable Care Act

IMPORTANCE

Under the Patient Protection and Affordable Care Act (ACA), US hospitals were exposed to a number of reforms intended to reduce spending, many of which, beginning in 2012, targeted acute care hospitals and often focused on specific diagnoses (eg, acute myocardial infarction, heart failure, and pneumonia) for Medicare patients. Other provisions enacted in the ACA and under budget sequestration (beginning in 2013) mandated Medicare fee cuts.

OBJECTIVE

To evaluate the association between the enactment of ACA reforms and 30-day price-standardized hospital episode spending.

DESIGN, SETTING, AND PARTICIPANTS

This policy evaluation included index discharges between January 1, 2008, and August 31, 2015, from a national random 20% sample of Medicare beneficiaries. Data analysis was performed from February 1, 2019 to July 8, 2020.

EXPOSURE

Payment reforms after passage of the ACA.

MAIN OUTCOMES AND MEASURES

30-day price-standardized episode payments. Three alternative estimation approaches were used to evaluate the association between reforms following the ACA and episode spending: (1) a difference-in-difference (DID) analysis among acute care hospitals, comparing spending for diagnoses commonly targeted by ACA programs with nontargeted diagnoses; (2) a DID analysis comparing acute care hospitals and critical access hospitals (not exposed to reforms); and (3) a generalized synthetic control analysis, comparing acute care and critical access hospitals. Supplemental analysis examined the degree to which Medicare fee cuts contributed to spending reductions.

RESULTS

A total of 7 634 242 index discharges (4 525 630 [59.2%] female patients; mean [SD] age, 79.31 [8.02] years) were included. All 3 approaches found that reforms following the ACA were associated with a significant reduction in episode spending. The DID estimate comparing targeted and untargeted diagnoses suggested that reforms following the ACA were associated with a -$431 (95% CI, -$492 to -$369; -2.87%) change in total spending, while the generalized synthetic control analysis suggested that reforms were associated with a -$1232 (95% CI, -$1488 to -$965; -10.12%) change in total episode spending, amounting in a total annual savings of $5.68 billion. Cuts to Medicare fees accounted for most of these savings.

CONCLUSIONS AND RELEVANCE

In this policy evaluation, the ACA was associated with large reductions in US hospital episode spending.

The Role Of Social, Cognitive, And Functional Risk Factors In Medicare Spending For Dual And Nondual Enrollees

The Centers for Medicare and Medicaid Services is increasingly focused on value-based payment programs, which tie payment to performance on quality and cost measures. In this context, there is rising concern that such programs systematically disadvantage providers that care for vulnerable populations, such as the poor, by holding the providers accountable for factors beyond their control that influence patient outcomes and utilization. In this nationally representative study of Medicare beneficiaries, we found that dually enrolled Medicare beneficiaries (those also enrolled in Medicaid) had strikingly higher levels of medical, functional, and cognitive comorbidities, as well as social needs, compared to their non-dually enrolled counterparts. Dual enrollees also had significantly higher annual costs of care. Including functional, cognitive, and social factors in cost prediction, in addition to risk factors derived from medical claims, improved risk prediction and decreased differences between dual and nondual enrollees. Medicare could consider such adjustment to improve accuracy and fairness in value-based payment programs.

State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment

OBJECTIVE

To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment.

DATA SOURCE

2010-2013 Medicare Current Beneficiary Survey.

STUDY DESIGN

Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies.

PRINCIPAL FINDINGS

Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs.

CONCLUSIONS

Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

Association of Patient Social, Cognitive, and Functional Risk Factors with Preventable Hospitalizations: Implications for Physician Value-Based Payment

BACKGROUND

Ambulatory care-sensitive condition (ACSC) hospitalizations are used to evaluate physicians' performance in Medicare value-based payment programs. However, these measures may disadvantage physicians caring for vulnerable populations because they omit social, cognitive, and functional factors that may be important determinants of hospitalization.

OBJECTIVE

To determine whether social, cognitive, and functional risk factors are associated with ACSC hospitalization rates and whether adjusting for them changes outpatient safety-net providers' performance.

DESIGN

Using data from the Medicare Current Beneficiary Survey, we conducted patient-level multivariable regression to estimate the association (as incidence rate ratios (IRRs)) between patient-reported social, cognitive, and functional risk factors and ACSC hospitalizations. We compared outpatient safety-net and non-safety-net providers' performance after adjusting for clinical comorbidities alone and after additional adjustment for social, cognitive, and functional factors captured in survey data.

SETTING

Safety-net and non-safety-net clinics.

PARTICIPANTS

Community-dwelling Medicare beneficiaries contributing 38,616 person-years from 2006 to 2013.

MEASUREMENTS

Acute and chronic ACSC hospitalizations.

RESULTS

After adjusting for clinical comorbidities, Alzheimer's/dementia (IRR 1.30, 95% CI 1.02-1.65), difficulty with 3-6 activities of daily living (ADLs) (IRR 1.43, 95% CI 1.05-1.94), difficulty with 1-2 instrumental ADLs (IADLs, IRR 1.54, 95% CI 1.26-1.90), and 3-6 IADLs (IRR 1.90, 95% CI 1.49-2.43) were associated with acute ACSC hospitalization. Low income (IRR 1.28, 95% CI 1.03-1.58), lack of educational attainment (IRR 1.33, 95% CI 1.04-1.69), being unmarried (IRR 1.18, 95% CI 1.01-1.36), difficulty with 1-2 IADLs (IRR 1.30, 95% CI 1.05-1.60), and 3-6 IADLs (IRR 1.44, 95% CI 1.16-1.80) were associated with chronic ACSC hospitalization. Adding these factors to standard Medicare risk adjustment eliminated outpatient safety-net providers' performance gap (p < .05) on ACSC hospitalization rates relative to non-safety-net providers.

CONCLUSIONS

Social, cognitive, and functional risk factors are independently associated with ACSC hospitalizations. Failure to account for them may penalize outpatient safety-net providers for factors that are beyond their control.

How Patient Complexity and Surgical Approach Influence Episode-Based Payment Models for Colectomy

BACKGROUND

Bundled payment programs broaden hospitals' responsibility for spending to entire episodes of care. After demonstration programs in cardiac surgery and joint replacement, these payment reforms could soon extend to major operations like colectomy under Medicare's Bundled Payments for Care Improvement - Advanced Model.

OBJECTIVE

This study aims to evaluate how specific policies and surgical practice patterns would influence hospital reimbursement in a bundled payment program for colectomy.

DESIGN

This was a population-based study.

SETTINGS

We used national data from the 100% Medicare Provider Analysis and Review files for the years 2010 to 2014.

PATIENTS

We identified patients undergoing colon resections by using diagnosis-related group codes and International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOME MEASURES

We simulated per case reconciliation payments as the difference between actual price-standardized 90-day episode payments and estimated regional spending benchmarks among fee-for-service Medicare beneficiaries undergoing colectomy (2010-2014).We projected per patient and overall hospital-level reconciliation payments and the proportion of hospitals that would achieve shared savings under bundled payment conditions. We also assessed how variation in the use of laparoscopy could influence shared savings, using instrumental variable methods to account for selection bias between laparoscopic and open procedures.

RESULTS

Under simulated bundled payment conditions, 51.8% of hospitals would achieve shared savings, but the average case would incur a reconciliation penalty of -$234 (95% CI, -$245 to -$223). Risk adjustment would increase the proportion of hospitals with shared savings to 54.3% (per case payment, +$237; 95% CI, $96-$379). Hospitals performing a greater proportion of cases laparoscopically would achieve higher per case reconciliation payments. For example, per case reconciliation penalties would be -$472 (95% CI, -$506 to -$438) for hospitals that performed 10% of their procedures laparoscopically, whereas those that performed 70% laparoscopically would receive payments of +$294 (95% CI, $262-$326).

LIMITATIONS

Alternative payment models for colectomy have not yet been introduced.

CONCLUSIONS

Surgical leaders must be prepared with strategies for optimizing episode efficiency. Inclusion of risk adjustment in bundled payment calculations and expanding utilization of laparoscopic surgery may represent approaches to achieve shared savings and improve surgeon engagement in alternative payment models for surgical care. See Video Abstract at http://links.lww.com/DCR/A928.

Social Risk Adjustment of Quality Measures for Diabetes and Cardiovascular Disease in a Commercially Insured US Population

IMPORTANCE

Patients' social risk factors may be associated with physician group performance on quality measures.

OBJECTIVE

To examine the association of social risk with change in physician group performance on diabetes and cardiovascular disease (CVD) quality measures in a commercially insured population.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study using claims data from 2010 to 2014 from a US national health insurance plan, the performance of 1400 physician groups (physicians billing under the same tax identification number) was estimated. After base adjustments for age and sex, changes in variation across groups and reordering of rankings resulting from additional adjustments for clinical, social, or both clinical and social risk factors were analyzed. In all models, only within-group associations were adjusted to distinguish the association of patients' social risk factors with outcomes while excluding physician groups' distinct characteristics that could also change observed performance. Data analysis was conducted between April and July 2018.

MAIN OUTCOMES AND MEASURES

Process measures (hemoglobin A1c [HbA1c] testing, low-density lipoprotein cholesterol [LDL-C] testing, and statin use), disease control measures (HbA1c and LDL-C level control), and use-based outcome measures (hospitalizations for ambulatory-sensitive conditions) were calculated with base adjustment (age and sex), clinical adjustment, social risk factor adjustment, and both clinical and social adjustments. Quality variance in physician group performance and changes in rankings following these adjustments were measured.

RESULTS

This study identified 1 684 167 enrollees (859 618 [51%] men) aged 18 to 65 years (mean [SD] age, 50 [10.7] years) with diabetes or CVD. Performance rates were high for HbA1c and LDL-C level testing (mean ranged from 79.5% to 87.2%) but lower for statin use (54.7% for diabetes cohort and 44.2% for CVD cohort) and disease control measures (57.9% on LDL-C control for diabetes cohort and 40.0% for CVD cohort). On average, only 8.8% of enrollees with diabetes and 1.0% of enrollees with CVD in a group were hospitalized. The addition of clinical and social risk factors to base adjustment reduced variance across physician groups for most measures (percentage change in SD ranged from -13.9% to 1.6%). Although overall agreement between performance scores with base vs full adjustment was high, there was still substantial reordering for some measures. For example, social risk adjustment resulted in reordering for disease control in the diabetes cohort. Of the 1400 physician groups, 330 (23.6%) had performance rankings for HbA1c control that increased or decreased by at least 10 percentile points after adding social risk factors to age and sex. Both clinical and social risk adjustment affected rankings on hospital admissions.

CONCLUSIONS AND RELEVANCE

Accounting for social risk may be important to mitigate adverse consequences of performance-based payments for physician groups serving socially vulnerable populations.

Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries

The Medicare Shared Savings Program (MSSP) adjusts savings benchmarks by beneficiaries' baseline risk scores. To discourage increased coding intensity, the benchmark is not adjusted upward if beneficiaries' risk scores rise while in the MSSP. As a result, accountable care organizations (ACOs) have an incentive to avoid increasingly sick or expensive beneficiaries. We examined whether beneficiaries' exposure to the MSSP was associated with within-beneficiary changes in risk scores and whether risk scores were associated with entry to or exit from the MSSP. We found that the MSSP was not associated with consistent changes in within-beneficiary risk scores. Conversely, beneficiaries at the ninety-fifth percentile of risk score had a 21.6 percent chance of exiting the MSSP, compared to a 16.0 percent chance among beneficiaries at the fiftieth percentile. The decision not to upwardly adjust risk scores in the MSSP has successfully deterred coding increases but might discourage ACOs to care for high-risk beneficiaries in the MSSP .

Comparison of the Complexity of Patients Seen by Different Medical Subspecialists in a Universal Health Care System

IMPORTANCE

Clinical experience suggests that there are substantial differences in patient complexity across medical specialties, but empirical data are lacking.

OBJECTIVE

To compare the complexity of patients seen by different types of physician in a universal health care system.

DESIGN, SETTING, AND PARTICIPANTS

Population-based retrospective cohort study of 2 597 127 residents of the Canadian province of Alberta aged 18 years and older with at least 1 physician visit between April 1, 2014 and March 31, 2015. Data were analyzed in September 2018.

EXPOSURES

Type of physician seeing each patient (family physician, general internist, or 11 types of medical subspecialist) assessed as non-mutually exclusive categories.

MAIN OUTCOMES AND MEASURES

Nine markers of patient complexity (number of comorbidities, presence of mental illness, number of types of physicians involved in each patient's care, number of physicians involved in each patient's care, number of prescribed medications, number of emergency department visits, rate of death, rate of hospitalization, rate of placement in a long-term care facility).

RESULTS

Among the 2 597 127 participants, the median (interquartile range) age was 46 (32-59) years and 54.1% were female. Over 1 year of follow-up, 21 792 patients (0.8%) died, the median (range) number of days spent in the hospital was 0 (0-365), 8.1% of patients had at least 1 hospitalization, and the median (interquartile range) number of prescribed medications was 3 (1-7). When the complexity markers were considered individually, patients seen by nephrologists had the highest mean number of comorbidities (4.2; 95% CI, 4.2-4.3 vs [lowest] 1.1; 95% CI, 1.0-1.1), highest mean number of prescribed medications (14.2; 95% CI, 14.2-14.3 vs [lowest] 4.9; 95% CI, 4.9-4.9), highest rate of death (6.6%; 95% CI, 6.3%-6.9% vs [lowest] 0.1%; 95% CI, <0.1%-0.2%), and highest rate of placement in a long-term care facility (2.0%; 95% CI, 1.8%-2.2% vs [lowest] <0.1%; 95% CI, <0.1%-0.1%). Patients seen by infectious disease specialists had the highest complexity as assessed by the other 5 markers: rate of a mental health condition (29%; 95% CI, 28%-29% vs [lowest] 14%; 95% CI, 14%-14%), mean number of physician types (5.5; 95% CI, 5.5-5.6 vs [lowest] 2.1; 95% CI, 2.1-2.1), mean number of physicians (13.0; 95% CI, 12.9-13.1 vs [lowest] 3.8; 95% CI, 3.8-3.8), mean days in hospital (15.0; 95% CI, 14.9-15.0 vs [lowest] 0.4; 95% CI, 0.4-0.4), and mean emergency department visits (2.6; 95% CI, 2.6-2.6 vs [lowest] 0.5; 95% CI, 0.5-0.5). When types of physician were ranked according to patient complexity across all 9 markers, the order from most to least complex was nephrologist, infectious disease specialist, neurologist, respirologist, hematologist, rheumatologist, gastroenterologist, cardiologist, general internist, endocrinologist, allergist/immunologist, dermatologist, and family physician.

CONCLUSION AND RELEVANCE

Substantial differences were found in 9 different markers of patient complexity across different types of physician, including medical subspecialists, general internists, and family physicians. These findings have implications for medical education and health policy.

Data Collection, EHRs, and Poverty Determinations

Collecting and deploying poverty-related data is an important starting point for leveraging data regarding social determinants of health in precision medicine. However, we must rethink how we collect and deploy such data. Current modes of collection yield imprecise data that is unsuited for research. Better data can be collected by cross-referencing other sources such as employers and public benefit programs, and by incentivizing and encouraging patients and providers to provide more accurate information. Data thus collected can be used to provide appropriate individual-level clinical and non-clinical care, and to systematically determine what share of social resources healthcare should consume.

The Stability of Physician-Specific Episode Costs for Urologic Cancer Surgery: Implications for Urologists Under the Merit-Based Incentive Program

OBJECTIVE

To evaluate the stability of physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy in the context of value-based purchasing programs, such as the merit-based incentive payment system.

METHODS

We utilized Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 who underwent a prostatectomy, nephrectomy, or cystectomy from 2008 to 2012. We calculated each surgeon's average 90-day episode payment by procedure. Next, we examined payment differences between the most and least expensive quartile providers. For the most expensive quartile of physicians in 2010, we examined their spending quartile in 2011. Finally, we evaluated the correlation in spending over time and across procedures.

RESULTS

We identified 14,585 patients who underwent surgery by one of 1895 unique clinicians. Differences in payments between the highest and lowest quartiles were $5881, $17,714, and $40,288 for prostatectomy, nephrectomy, and cystectomy, respectively. Only 39%, 16%, and 13% of physicians that were in the highest spending quartile for prostatectomy, nephrectomy, and cystectomy in 2010 were also in the most expensive quartile in 2011. Although we observed weak correlation in year-to-year spending for prostatectomy (0.108, P = .033 to .270, P < .001), annual payments for nephrectomy and cystectomy were not significantly correlated. Finally, there was minimal correlation in surgeon spending across procedures.

CONCLUSION

There is wide variation in physician-specific episode payments for prostatectomy, nephrectomy, and cystectomy. However, physician spending patterns are not stable over time or across procedures, raising concerns about the ability of the cost-based measures in merit-based incentive payment system to change physician behavior and reliably distinguish those providing less efficient or lower quality care.

Sprint to work: A novel model for team science collaboration in academic medicine

Collaborative research in academic medicine is often inefficient and ineffective. It often fails to leverage the expertise of interdisciplinary team members, does not seek or incorporate team input at opportune times, and creates workload inequities. Adapting approaches developed in venture capital, we created the 'sprint model' for writing academic papers based on the analysis of secondary data. The 'sprint model' minimizes common barriers that undermine collaboration in academic medicine. This model for team science collaboration begins with team members convening for a highly focused, guided session. In this session, a facilitator moves the group through a structured process to create the study plan. This includes refining the research questions, developing the study design, and prototyping the presentation of results. After adopting this model, our team has drastically reduced time from idea inception to final product submission through increased efficiencies and reduced redundancies. From December 2016 to April 2018, our team has initiated 15 paper sprints. The median time from sprint to submission for paper sprints has been 1.7 months (minimum: 0.5; maximum: 9). Although our current 'sprint' approach has already demonstrated a substantial improvement in our ability to rapidly produce high-quality research, we believe the 'pre-sprint' preparation and 'post-sprint' processes can be further refined. Finally, we discuss the limitations of this model and our efforts to adapt the process to meet the evolving needs of research teams.