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In this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR.

ObjectiveTo evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use.DesignQuasi-experimental difference-in-differences analysis.SettingUS hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals.Participants238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals.Main outcome measuresPrimary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply.ResultsIn the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change −0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (−1.2%, 95% confidence interval −2.3% to −0.2%). Spending on care at skilled nursing facilities decreased (−6.3%, −10.0% to −2.5%) owing to a reduced number of facility days (−6.2%, −9.8% to −2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (−0.1 percentage points, 95% confidence interval −0.5 to 0.2 percentage points).ConclusionsIn this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

Investigating the interaction between fins can guide the design and enhance the performance of robotic fish. In this paper, we take boxfish as the bionic object and discuss the effect of coupling motion gaits among the two primary propulsors, pectoral and caudal fins, on the heading stability of the body. First, we propose the structure and control system of the bionic boxfish prototype. Second, using a one/two-way fluid–structure interaction numerical method, we analyse the key parameters of the prototype and discuss the influence of pectoral and caudal motion gaits on the hydrodynamic performance. Finally, effect of the pectoral and caudal interactions on heading stability of the prototype is systematically analyzed and verified in experiments. Results show that the course-deviating degree, oscillation amplitudes of yawing, rolling, and pitching exhibited by the prototype are smaller than that caused by single propulsor when the motion gaits of both pectoral and caudal fins are coordinated in a specific range. This paper reveals for the first time the effect of interactions between pectoral and caudal fins, on the stability of body's course by means of Computational Fluid Dynamics and prototype experiments, which provides an essential guidance for the design of robotic fish propelled by multi-fins.