Do Bundled Payment Programs in Joint Replacement Care Hold Promise for Improving Patient Outcomes?

The Centers for Medicare and Medicaid Services (CMS) Innovation Center offers two alternative payment models for joint replacement: the voluntary Bundled Payment for Care Improvement (BPCI) model and the mandatory Comprehensive Care for Joint Replacement (CJR) model. As CMS considers methods for cost reduction, research is needed to understand patient-level outcomes and organizational-level success factors. A retrospective cross-sectional study of hospitals was performed, using regression models to evaluate an aggregate patient satisfaction score, complication rates, and operational differences among BPCI, CJR, and nonparticipating hospitals. Results show that BPCI hospitals received significantly better patient satisfaction scores (88.6) than CJR hospitals (86.0), but complication rates were not significantly different between CJR and BPCI hospitals (2.83 and 2.77, respectively). Factors associated with BPCI participation include academic affiliation, a Northeast region locale, and having a higher CMS efficiency score. Thus, requiring more hospitals to participate in CMS-bundled payment programs as a federal policy may not be the optimal way to improve patient satisfaction and outcomes. Rather, the CJR and BPCI programs should be further studied, and the results generalized for use by nonparticipating hospitals to encourage preparation and participation in CMS value-based initiatives.

Submesoscale dispersion in the vicinity of the Deepwater Horizon spill.

Reliable forecasts for the dispersion of oceanic contamination are important for coastal ecosystems, society, and the economy as evidenced by the Deepwater Horizon oil spill in the Gulf of Mexico in 2010 and the Fukushima nuclear plant incident in the Pacific Ocean in 2011. Accurate prediction of pollutant pathways and concentrations at the ocean surface requires understanding ocean dynamics over a broad range of spatial scales. Fundamental questions concerning the structure of the velocity field at the submesoscales (100 m to tens of kilometers, hours to days) remain unresolved due to a lack of synoptic measurements at these scales. Using high-frequency position data provided by the near-simultaneous release of hundreds of accurately tracked surface drifters, we study the structure of submesoscale surface velocity fluctuations in the Northern Gulf of Mexico. Observed two-point statistics confirm the accuracy of classic turbulence scaling laws at 200-m to 50-km scales and clearly indicate that dispersion at the submesoscales is local, driven predominantly by energetic submesoscale fluctuations. The results demonstrate the feasibility and utility of deploying large clusters of drifting instruments to provide synoptic observations of spatial variability of the ocean surface velocity field. Our findings allow quantification of the submesoscale-driven dispersion missing in current operational circulation models and satellite altimeter-derived velocity fields.

Surface evolution of the deepwater horizon oil spill patch: combined effects of circulation and wind-induced drift.

Following the Deepwater Horizon blowout, major concerns were raised about the probability that the Loop Current would entrain oil at the surface of the Gulf of Mexico toward South Florida. However, such a scenario did not materialize. Results from a modeling approach suggest that the prevailing winds, through the drift they induced at the ocean surface, played a major role in pushing the oil toward the coasts along the northern Gulf, and, in synergy with the Loop Current evolution, prevented the oil from reaching the Florida Straits. This implies that both oceanic currents and surface wind-induced drift must be taken into account for the successful forecasting of the trajectories and landfall of oil particles, even in energetic environments such as the Gulf of Mexico. Consequently, the time range of these predictions is limited to the weather forecasting range, in addition to the range set up by ocean forecasting capabilities.

Dynamic autoinoculation and the microbial ecology of a deep water hydrocarbon irruption.

The irruption of gas and oil into the Gulf of Mexico during the Deepwater Horizon event fed a deep sea bacterial bloom that consumed hydrocarbons in the affected waters, formed a regional oxygen anomaly, and altered the microbiology of the region. In this work, we develop a coupled physical-metabolic model to assess the impact of mixing processes on these deep ocean bacterial communities and their capacity for hydrocarbon and oxygen use. We find that observed biodegradation patterns are well-described by exponential growth of bacteria from seed populations present at low abundance and that current oscillation and mixing processes played a critical role in distributing hydrocarbons and associated bacterial blooms within the northeast Gulf of Mexico. Mixing processes also accelerated hydrocarbon degradation through an autoinoculation effect, where water masses, in which the hydrocarbon irruption had caused blooms, later returned to the spill site with hydrocarbon-degrading bacteria persisting at elevated abundance. Interestingly, although the initial irruption of hydrocarbons fed successive blooms of different bacterial types, subsequent irruptions promoted consistency in the structure of the bacterial community. These results highlight an impact of mixing and circulation processes on biodegradation activity of bacteria during the Deepwater Horizon event and suggest an important role for mixing processes in the microbial ecology of deep ocean environments.

Deep brain stimulation in a patient on immunosuppressive therapy after renal transplant.

We performed thalamic deep brain stimulation (DBS) surgery to treat severe essential tremor in a 36 year-old woman who had undergone cadaveric renal transplant four years earlier. She was receiving chronic immunosuppressive therapy. Post-operative healing was normal and there have been no infections of the DBS hardware. There were no peri-operative complications and no rejection of the transplanted kidney. She remains on the same systemic immunosuppressive agents as pre-operatively: prednisone, cyclosporine, and mycophenolate mofetil (CellCept). DBS surgery may be safely performed in carefully selected patients on systemic immunosuppression after renal transplant.