Association of Maryland Global Budget Revenue With Spending and Outcomes Related to Surgical Care for Medicare Beneficiaries With Cancer.

Importance: In 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 (2011-2013) to after (2015-2018) 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 Measures: Thirty-day episode spending, mortality, readmissions, and emergency department (ED) visits. Results: Relative 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.

Maryland's Global Hospital Budgets--Preliminary Results from an All-Payer Model.

In the first year of Maryland's experiment in setting all-payer rates for hospital services, costs were contained and the quality of care improved, though the state still has high rates of hospital admissions and per capita spending for Medicare patients.

Effect of steroid and antibiotic treatment during assisted hatching on IVF outcomes.

There are limited data on the use of steroids and antibiotics in assisted reproductive technology (ART). Our aim was to evaluate the impact of these treatments on the outcome of IVF cycles in which Assisted Hatching (AH) was performed. We studied a retrospective cohort in a large university-affiliated infertility centre. Data from 1126 AH cycles performed between 2007 and 2009 were reviewed. Cycles were categorized as "treatment" (n = 640) and "no treatment" (n = 486), depending on whether they received steroids and antibiotics. The primary outcome was live birth. Secondary outcomes included implantation, spontaneous abortion, biochemical, clinical and ectopic pregnancy. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). OR were adjusted (AOR) for age, BMI, baseline FSH, peak estradiol, cycle number, number of oocytes retrieved, number of embryos that underwent AH, number of high-implantation potential embryos, number of embryos transferred and physician in charge. The AOR (95% CI) of live birth was 1.91 (1.08-3.38), of clinical pregnancy, 1.75 (1.08-2.83) and of biochemical pregnancy, 0.24 (0.07-0.85). Our study suggests that treatment with steroids and antibiotics during AH cycles significantly increases the odds of live birth.

Can the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) be used to accurately report clinic total reproductive potential (TRP)?

OBJECTIVE: To assess whether total reproductive potential (TRP), the chance of a live birth from each fresh cycle (fresh cycle plus frozen transfers), could be calculated from the national Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) database and whether information not available in SART CORS resulted in significant changes to the TRP calculation. DESIGN: Retrospective study using SART CORS and clinic data. SETTING: Three assisted reproductive technology clinics. PATIENT(S): Women undergoing ART. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Two- and three-year TRPs for 2005 and 2006 were calculated according to patient age at cycle start by linking fresh to frozen cycles up to first live birth. Clinic records were used to adjust for (remove) frozen cycles that used more than one fresh cycle as a source of embryos and for any embryos donated to other patients or research or shipped to another facility before a live birth. RESULT(S): TRP was higher than fresh per-cycle rates for most ages at all clinics, although accuracy was compromised when there were fewer than 20 cycles per category. Two- and 3-year TRPs differed in only 2 of 24 calculations. Adjusted TRPs differed less than three percentage points from unadjusted TRPs when volume was sufficient. CONCLUSION(S): Clinic TRP can be calculated from SART CORS. Data suggest that calculations of clinic TRP from the national dataset would be meaningful.

Prognosis for clinical pregnancy and delivery after total fertilization failure during conventional in vitro fertilization or intracytoplasmic sperm injection.

OBJECTIVE: To determine the prognosis for clinical pregnancy and delivery after total fertilization failure. DESIGN: Retrospective analysis of patient treatment cycles. SETTING: Private fertility clinic. PATIENT(S): 555 couples who had total fertilization failure during a cycle of conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Delivery rates, peak estradiol level, number of mature follicles, number of oocytes retrieved, number of mature oocytes, sperm concentration, and sperm motility. RESULT(S): Delivery rates for IVF patients who elected to continue treatment after fertilization failure were 44% per patient, 25% per embryo transfer (ET), and 22% per cycle. Delivery rates for ICSI patients were 36% per patient, 23% per ET, and 18% per cycle. The number of mature oocytes was always statistically significantly lower in the total fertilization failure cycle when compared with fertilization cycles that occurred either before or after, whether ICSI or conventional IVF was involved. CONCLUSION(S): The prognosis for pregnancy is encouraging in subsequent cycles after total fertilization failure. Fertilization failure was a result of suboptimal response to ovarian stimulation.