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IMPORTANCE: It is critical to develop a better understanding of the strategies provider organizations use to improve the performance of frontline clinicians and whether ACO participation is associated with differential adoption of these tools. OBJECTIVES: Characterize the strategies that physician practices use to improve clinician performance and determine their association with ACOs and other payment reforms. DATA SOURCES: The National Survey of Healthcare Organizations and the National Survey of ACOs fielded 2017‐2018 (response rates = 47 percent and 48 percent). STUDY DESIGN: Descriptive analysis for practices participating and not participating in ACOs among 2190 physician practice respondents. Linear regressions to examine characteristics associated with counts of performance domains for which a practice used data for feedback, quality improvement, or physician compensation as dependent variables. Logistic and fractional regression to examine characteristics associated with use of peer comparison and shares of primary care and specialist compensation accounted for by performance bonuses, respectively. PRINCIPAL FINDINGS: ACO‐affiliated practices feed back clinician‐level information and use it for quality improvement and compensation on more performance domains than non‐ACO‐affiliated practices. Performance measures contribute little to physician compensation irrespective of ACO participation. CONCLUSION: ACO‐affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.

Success of the accountable care organization model may require stronger financial incentives, potentially by including downside financial risk in contracts. Using the National Survey of ACOs, we explored changes in ACO structure and contracts over time. Though the number of ACO contracts and proportion with multiple contracts has grown, the proportion of ACOs bearing downside risk increased only modestly.

OBJECTIVE: To examine changes in more and less discretionary condition-specific post-acute care use (skilled nursing, inpatient rehabilitation, home health) associated with Medicare accountable care organization (ACO) implementation. DATA SOURCES: 2009–2014 Medicare fee-for-service claims. STUDY DESIGN: Difference-in-difference methodology comparing post-acute outcomes after hospitalization for hip fracture and stroke (where rehabilitation is fundamental to the episode of care) to pneumonia, (where it is more discretionary) for beneficiaries attributed to ACO and non-ACO providers. PRINCIPAL FINDINGS: Across all three cohorts, in the baseline period ACO patients were more likely to receive Medicare-paid post-acute care and had higher episode spending. In hip fracture patients where rehabilitation is standard of care, ACO implementation was associated with 6–8% increases in probability of admission to a skilled nursing facility or inpatient rehabilitation (compared to home without care), and a slight reduction in readmissions. In a clinical condition where rehabilitation is more discretionary, pneumonia, ACO implementation was not associated with changes in post-acute location, but episodic spending decreased 2–3%. Spending decreases were concentrated in the least complex patients. Across all cohorts, the length of stay in skilled nursing facilities decreased with ACO implementation. CONCLUSIONS: ACOs decreased spending on post-acute care by decreasing use of discretionary services. ACO implementation was associated with reduced length of stay in skilled nursing facilities, while hip fracture patients used institutional post-acute settings at higher rates. Among pneumonia patients, we observed decreases in spending, readmission days, and mortality associated with ACO implementation.

Background The endothelial glycocalyx layer (EGL) is a key regulator of vascular permeability, cell adhesion, and inflammation. The EGL is primarily composed of syndecan-1, hyaluronic acid (HA), heparan sulfate (HS) and chondroitin sulfate (CS). While many studies have observed increased shedding of syndecan-1 during hemorrhagic shock, little is known about the shedding of other EGL components, and their effects on altered permeability and coagulation. We characterized shedding of all four primary components of the EGL, as well as the plasma’s effect on permeability and thrombin generation in a cohort of trauma patients. Methods Plasma samples were collected from 5 healthy consented volunteers and 22 severely injured trauma patients upon admission to the emergency department. ELISA assays were performed to quantify shed HA, HS, CS and syndecan-1 in plasma. A colloid osmometer and Electric Cell-substrate Impedance Sensing (ECIS) system were used to measure plasma colloid osmotic pressure (COP) and cell permeability, respectively. Thrombin generation was measured using a calibrated automated thrombogram (CAT). Initial vital signs, routine laboratory values, and injury severity scores (ISS) were recorded. Non-parametric statistical tests were used to compare differences between groups. Results We observed increased shedding of all four proteins in trauma patient plasma compared to healthy controls: 31.7 vs. 21.2 U/L of CS, 175.8 vs. 121.9 ng/ml of HS, 946.7 vs. 618.6 ng/ml of HA and 245.8 vs. 31.6 ng/ml of syndecan-1 (all p

Background In sub-Saharan Africa, the prevalence of hepatitis B virus (HBV) is between 6–20%. In Zambia, prevalence of HIV and HBV co-infection has been reported to be between 7.1% and 31.1%. Patients infected with HBV are at increased risk of experiencing elevated alanine transaminase enzyme (ALT) and HIV-HBV co-infection may lead to further reduced CD4 cell count before initiating antiretroviral therapy (ART). We investigated the relation of HBV with CD4 cell count and ALT enzyme in HIV-positive antiretroviral therapy-naive patients. Methods This was a cross-sectional study conducted in 15 government clinics in Lusaka. There were 5436 adult patients who initiated antiretroviral therapy between 2011 and 2013. Cases were described as HIV-positive patients who tested HBsAg-positive and controls as HIV-positive patients who tested HBsAg-negative. HIV-HBV co-infection was defined as the number of patients who tested HBsAg-positive divided by the total tested (with 95% CI). Laboratory measures of CD4 and ALT were categorised in the analysis. Elevated ALT was defined as ALT≥66 IU/ml. CD4 cell count was dichotomised CD4 of >200 cells/µl. Results The median age was 35 (29–41) years. The median CD4 cell count was 202 (102–305) cells/µl with the median ALT being 20 (14–30) IU/ml. HIV−HBV prevalence was 12.3% (95% CI: 11.4−13.1). Elevated ALT was reported in 11.1% cases and 4.7% in controls (p-value Conclusions Prevalence of HBV is high among HIV-infected persons in Zambia. There is need to explore the interactions of these co-infections and their impact on CD4 cell count and ALT.