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Concept: Centers for Medicare and Medicaid Services

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Background Long-term treatment with supplemental oxygen has unknown efficacy in patients with stable chronic obstructive pulmonary disease (COPD) and resting or exercise-induced moderate desaturation. Methods We originally designed the trial to test whether long-term treatment with supplemental oxygen would result in a longer time to death than no use of supplemental oxygen among patients who had stable COPD with moderate resting desaturation (oxyhemoglobin saturation as measured by pulse oximetry [Spo2], 89 to 93%). After 7 months and the randomization of 34 patients, the trial was redesigned to also include patients who had stable COPD with moderate exercise-induced desaturation (during the 6-minute walk test, Spo2 ≥80% for ≥5 minutes and <90% for ≥10 seconds) and to incorporate the time to the first hospitalization for any cause into the new composite primary outcome. Patients were randomly assigned, in a 1:1 ratio, to receive long-term supplemental oxygen (supplemental-oxygen group) or no long-term supplemental oxygen (no-supplemental-oxygen group). In the supplemental-oxygen group, patients with resting desaturation were prescribed 24-hour oxygen, and those with desaturation only during exercise were prescribed oxygen during exercise and sleep. The trial-group assignment was not masked. Results A total of 738 patients at 42 centers were followed for 1 to 6 years. In a time-to-event analysis, we found no significant difference between the supplemental-oxygen group and the no-supplemental-oxygen group in the time to death or first hospitalization (hazard ratio, 0.94; 95% confidence interval [CI], 0.79 to 1.12; P=0.52), nor in the rates of all hospitalizations (rate ratio, 1.01; 95% CI, 0.91 to 1.13), COPD exacerbations (rate ratio, 1.08; 95% CI, 0.98 to 1.19), and COPD-related hospitalizations (rate ratio, 0.99; 95% CI, 0.83 to 1.17). We found no consistent between-group differences in measures of quality of life, lung function, and the distance walked in 6 minutes. Conclusions In patients with stable COPD and resting or exercise-induced moderate desaturation, the prescription of long-term supplemental oxygen did not result in a longer time to death or first hospitalization than no long-term supplemental oxygen, nor did it provide sustained benefit with regard to any of the other measured outcomes. (Funded by the National Heart, Lung, and Blood Institute and the Centers for Medicare and Medicaid Services; LOTT ClinicalTrials.gov number, NCT00692198 .).

Concepts: Asthma, Lung, Pneumonia, Chronic obstructive pulmonary disease, Emphysema, Centers for Medicare and Medicaid Services, Pulse oximetry, Oxygen therapy

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Section 3506 of the Affordable Care Act encourages use of shared decision making in health care, but progress on this front has been slow. The first step is for the Centers for Medicare and Medicaid Services to begin certifying and implementing patient decision aids.

Concepts: Health care, Health insurance, Centers for Medicare and Medicaid Services

59

October 1, 2012, marked the beginning of the Hospital Readmissions Reduction Program (HRRP), an ambitious effort by the Centers for Medicare and Medicaid Services (CMS) to reduce the frequency of rehospitalization of Medicare patients. The program consists primarily of financial penalties levied against hospitals with readmission rates that are deemed to be excessive. To assign penalties, CMS calculated expected readmission rates for all hospitalizations for acute myocardial infarction, congestive heart failure, and pneumonia from July 2008 through June 2011, adjusting for age, sex, and coexisting conditions such as diabetes and hypertension. These expected rates were then compared with the actual . . .

Concepts: Myocardial infarction, Hypertension, Hospital, Cardiology, Heart failure, Obesity, Stroke, Centers for Medicare and Medicaid Services

41

Nonadherence to taking prescribed antihypertensive medication (antihypertensive) regimens has been identified as a leading cause of poor blood pressure control among persons with hypertension and an important risk factor for adverse cardiovascular disease outcomes. CDC and the Centers for Medicare and Medicaid Services analyzed geographic, racial-ethnic, and other disparities in nonadherence to antihypertensives among Medicare Part D beneficiaries in 2014.

Concepts: Medicare, Blood pressure, Vital signs, Centers for Medicare and Medicaid Services, Health insurance in the United States, Medicare and Medicaid, Medicare Part D, Medicare Prescription Drug, Improvement, and Modernization Act

39

Background From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical-home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. Methods We examined the achievement of medical-home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients' experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference-in-differences analyses, we compared changes in outcomes in the two groups of sites during a 3-year period. Results Level 3 medical-home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures ($37 more per beneficiary per year, P=0.02). Demonstration-site participation was not associated with relative improvements in most measures of patients' experiences. Conclusions Demonstration sites had higher rates of medical-home recognition and smaller decreases in the number of patients' visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.).

Concepts: Better, Medicare, Health insurance, The Higher, Centers for Medicare and Medicaid Services, Medicaid, Health insurance in the United States, Medicare and Medicaid

31

On January 10, 2014, the Centers for Medicare and Medicaid Services (CMS) and the State of Maryland jointly announced the launch of a statewide model that will transform Maryland’s health care delivery system. Although some aspects of the new approach may be unique to Maryland and not applicable elsewhere, both the principles of this model and the process that led to its development may serve as a guide for future federal-state partnership efforts aiming to improve health care and to lower costs through an all-payer approach. Since the late 1970s, Maryland has operated what is now the country’s only all-payer . . .

Concepts: Health care, Medicare, Medicine, Health insurance, Health, Medical ethics, Centers for Medicare and Medicaid Services, Massachusetts

31

Under the Physician Payments Sunshine Act, drug and device manufacturers and group purchasing organizations will report to the Centers for Medicare and Medicaid Services payments made to physicians and teaching hospitals, and the data will be posted on a public website.

Concepts: Medicare, Health insurance, Hospital, Physician, Surgeon, Centers for Medicare and Medicaid Services, Medicaid, Residency

30

The Affordable Care Act (ACA) and the Center for Medicare and Medicaid Innovation emphasize accountable care organizations (ACOs) as mechanisms for achieving cost savings while ensuring high-quality care. ACOs are expected to contain costs through improvements in health care delivery and realignment of financial incentives, but their effectiveness remains unproved, and there are reasons for concern that they may fail.(1) Oregon has embarked on an ambitious program centered on the ACO model, which aims to change Medicaid financing and health care delivery. The Oregon experiment highlights both the bold vision of ACO-based health care reform and the potential challenges to . . .

Concepts: Health care, Medicare, Healthcare reform, Health insurance, Clinical trial, Economics, Centers for Medicare and Medicaid Services, Eugene, Oregon

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OBJECTIVE: Examine the mediating effect of injectable drugs in the relationship between dialysis facility organizational status and patient mortality. STUDY SETTING: Medicare dialysis population. STUDY DESIGN: Data from the U.S. Renal Data System (USRDS) were used to identify 3,884 freestanding dialysis facilities and 37,942 Medicare patients incident to end-stage renal disease (ESRD) in 2006. The role of injectable medications was evaluated during a 2-year follow-up period by mediational analyses using mixed-effect regression models. DATA COLLECTION: USRDS data were matched with Dialysis Facility Report data from Centers for Medicare and Medicaid Services (CMS) and census data. PRINCIPAL FINDINGS: There was a strong association found between organizational status and use of injectable drugs. Large for-profit chains used significantly higher injectable medications compared with nonprofit chains and independent facilities. However, the relationship between facility organizational status and patient mortality was not found to be mediated through the higher use of injectable drugs. CONCLUSIONS: Large for-profit chain facilities administered higher IV epoetin, iron, and vitamin D dosages, but this did not result in improved survival. Given the associated costs and lack of a survival benefit, the overuse of injectable medications among the U.S. dialysis patients will likely end under the recent bundling of injectable medications without jeopardizing patient outcomes.

Concepts: Renal failure, Chronic kidney disease, Kidney, Nephrology, Erythropoietin, Dialysis, Pharmaceutical drug, Centers for Medicare and Medicaid Services

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Background: The relationship between clinical decision support systems (CDSS) and quality is a relatively new, and in light of the new health information technology (HIT) legislation, policy-relevant area. Moreover, very few studies exist examining the link between HIT and healthcare disparities. The purpose of this article is to examine the association between CDSS and the treatment of pneumonia care within high-minority (≥29.1% non-white, non-Hispanic) and low-minority (<29.1%) Zip Code Tabulation Areas (ZCTAs). Research design: This study employed a cross-sectional design and used 2009 data from the American Hospital Association, the Centers for Medicare and Medicaid Services and the Research Triangle Institute. Adjusted analysis controlled for a hospital's propensity to use CDSS. Results: In the unadjusted analysis, hospitals in high-minority ZCTAs had lower pneumonia quality composite scores than their low-minority counterparts. When adjusting for other hospital and ZCTA-level variables, we found that CDSS use had stronger positive associations with quality in high-minority hospitals. Conclusions: Results support policy directives may support higher quality improvements by focusing CDSS adoption in high-minority hospitals.

Concepts: Health insurance, Decision theory, Decision support system, Centers for Medicare and Medicaid Services, Clinical decision support system, Decision engineering, Information systems, Data warehouse