Objective. To assess whether adoption of the patient-centered medical home (PCMH) reduces emergency department (ED) utilization among patients with and without chronic illness. Data Sources. Data from approximately 460,000 Independence Blue Cross patients enrolled in 280 primary care practices, all converting to PCMH status between 2008 and 2012. Research Design. We estimate the effect of a practice becoming PCMH-certified on ED visits and costs using a difference-in-differences approach which exploits variation in the timing of PCMH certification, employing either practice or patient fixed effects. We analyzed patients with and without chronic illness across six chronic illness categories. Principal Findings. Among chronically ill patients, transition to PCMH status was associated with 5-8 percent reductions in ED utilization. This finding was robust to a number of specifications, including analyzing avoidable and weekend ED visits alone. The largest reductions in ED visits are concentrated among chronic patients with diabetes and hypertension. Conclusions. Adoption of the PCMH model was associated with lower ED utilization for chronically ill patients, but not for those without chronic illness. The effectiveness of the PCMH model varies by chronic condition. Analysis of weekend and avoidable ED visits suggests that reductions in ED utilization stem from better management of chronic illness rather than expanding access to primary care clinics. Key Words. Patient-centered medical home, emergency department, chronic illnessThe patient-centered medical home (PCMH) model has shown early promise as a vehicle for reorganizing health care systems and improving the management of chronic illness. Studies of the medical home and related interventions have shown improvements in provider experience (Reid et al.

Infectious disease crises have substantial economic impact. Yet mainstream macroeconomic forecasting rarely takes account of the risk of potential pandemics. This oversight contributes to persistent underestimation of infectious disease risk and consequent underinvestment in preparedness and response to infectious disease crises. One reason why economists fail to include economic vulnerability to infectious disease threats in their assessments is the absence of readily available and digestible input data to inform such analysis. In this Viewpoint we suggest an approach by which the global health community can help to generate such inputs, and a framework to use these inputs to assess the economic vulnerability to infectious disease crises of individual countries and regions. We argue that incorporation of these risks in influential macroeconomic analyses such as the reports from the International Monetary Fund's Article IV consultations, rating agencies and risk consultancies would simultaneously improve the quality of economic risk forecasting and reinforce individual government and donor incentives to mitigate infectious disease risks.

OBJECTIVE To study the medical and financial outcomes associated with surgery in the elderly obese patient and ask if obesity itself influences outcomes above and beyond effects from comorbidities known to be associated with obesity. BACKGROUND Obesity is a surgical risk factor not present in Medicare’s risk adjustment or payment algorithms, as BMI is not collected in administrative claims. METHODS 2045 severely or morbidly obese patients (BMI ≥ 35 kg/m2, age between 65 and 80) selected from 15,914 elderly patients in 47 hospitals undergoing hip and knee surgery, colectomy, and thoracotomy were matched to two sets of 2045 non-obese patients (BMI = 20 – 30 kg/m2). A “limited match” controlled for age, sex, race, procedure and hospital. A “complete match” also controlled for 30 additional factors such as diabetes and admission clinical data from chart abstraction. RESULTS Mean BMI in the obese was 40kg/m2 versus 26kg/m2 in the non-obese. In the complete match, obese patients displayed increased odds of wound infection: OR = 1.64 (95% CI 1.21, 2.21); renal dysfunction: OR = 2.05(1.39, 3.05); urinary tract infection: OR = 1.55 (1.24, 1.94); hypotension: OR = 1.38 (1.07, 1.80); respiratory events: OR = 1.44 (1.19, 1.75); 30-day readmission: OR = 1.38 (1.08, 1.77); and a 12% longer length of stay (8%, 17%); Provider costs were 10% (7%, 12%) greater in the obese than non-obese, while Medicare payments increased only 3% (2%, 5%). Findings were similar in the limited match. CONCLUSIONS Obesity increases the risks and costs of surgery. Better approaches are needed to reduce these risks. Furthermore, to avoid incentives to under-serve this population, Medicare should consider incorporating incremental costs of caring for obese patients into payment policy and include obesity in severity adjustment models.

Over the past two decades, live kidney donation by older individuals (≥55 years) has become more common. Given strong associations of older age with cardiovascular disease, nephrectomy could make older donors vulnerable to death and cardiovascular events. We performed a cohort study among older live kidney donors who were matched to healthy older individuals in the Health and Retirement Study. The primary outcome was mortality ascertained through national death registries. Secondary outcomes ascertained among pairs with Medicare coverage included death or cardiovascular disease ascertained through Medicare claims data. During the period from 1996 – 2006, there were 5717 older donors in the United States. We matched 3368 donors 1:1 to older healthy non-donors. Among donors and matched pairs, the mean age was 59 years; 41% were male and 7% were black race. In median follow-up of 7.8 years, mortality was not different between donors and matched pairs (p=0.21). Among donors with Medicare, the combined outcome of death/CVD (p=0.70) was also not different between donors and non-donors. In summary, carefully selected older kidney donors do not face a higher risk of death or CVD. These findings should be provided to older individuals considering live kidney donation.

Objective To investigate the association between obesity and perioperative acute kidney injury (AKI), controlling for preoperative kidney dysfunction. Summary Background Data More than 30% of patients over the age of 60 are obese, and therefore at risk for kidney disease. Post-operative AKI is a significant problem. Methods We performed a matched case control study of patients enrolled in the Obesity and Surgical Outcomes Study (OBSOS), using Medicare claims data enriched with detailed chart review. Each AKI patient was matched to a non-AKI control similar in procedure type, age, sex, race, emergency status, transfer status, baseline eGFR, admission APACHE score, and the risk of death score with fine balance on hospitals. Results We identified 514 AKI cases and 694 control patients. Of the cases, 180 (35%) followed orthopedic procedures and 334 (65%) followed colon or thoracic surgery. After matching, obese patients undergoing a surgical procedure demonstrated a 65% increase in odds of AKI within 30 days from admission (OR=1.65, p<0.005) when compared to the non-obese patients. After adjustment for potential confounders, the odds of post-operative AKI remained elevated in the elderly obese (OR=1.68, p=0.01.) Conclusions Obesity is an independent risk factor for post-operative AKI in patients over 65 years of age. Efforts to optimize kidney function pre-operatively should be employed in this at risk population along with keen monitoring and maintenance of intra-operative hemodynamics. When subtle reductions in urine output or a rising creatinine are observed post-operatively, timely clinical investigation is warranted to maximize renal recovery.