Metric Selection,Metric Targets,and Risk Adjustment Should be Considered in the Design of Gainsharing Models for Bundled Payment Programs in Total Joint Arthroplasty

BackgroundUnder bundled payment models, gainsharing presents an important mechanism to ensure engagement and reward innovation. We hypothesized that metric selection, metric targets, and risk adjustment would impact surgeons’ performance in gainsharing models.MethodsPatients undergoing total joint arthroplasty at an urban health system from 2017 to September 2018 were included. Gainsharing metrics included the following: length of stay, % discharge-to-home, 90-day readmission rate, % of patients with episode spend under target price, and % of patients with patient-reported outcomes (PROs) collected. Four scenarios were created to evaluate how metric selection/adjustment impacted surgeons’ performance designation: scenario 1 used “aspirational targets” (>60th percentile), scenario 2 used “acceptable targets” (>50th percentile), scenario 3 risk-adjusted surgeon performance prior to comparing aspirational targets, and scenario 4 included a PRO collection metric. Number of metrics achieved determined performance tier, with higher tiers getting a greater share of the gainsharing pool.ResultsIn total, 2776 patients treated by 12 surgeons met inclusion criteria (mean length of stay 3.0 days, readmission rate 4.0%, discharge-to-home 74%, episode spend under target price 85%, PRO collection 56%). Lowering of metric targets (scenario 1 vs. 2) resulted in a 75% increase in the number of high performers and 98% of the gainsharing pool being eligible for distribution. Risk adjustment (scenario 3) caused 50% of providers to move to higher performance tiers and potential payments to increase by 28%. Adding the PRO metric did not change performance.ConclusionQuality metric/target selection and risk adjustment profoundly impact surgeons’ performance in gainsharing contracts. This impacts how successful these contracts can be in driving innovation and dis-incentivizing the “cherry picking” of patients.Level of evidenceLevel III.     

Drug release kinetics of temperature sensitive liposomes measured at high-temporal resolution with a millifluidic device

Purpose: Current release assays have inadequate temporal resolution (?～?10?s) to characterise temperature sensitive liposomes (TSL) designed for intravascular triggered drug release, where release within the first few seconds is relevant for drug delivery.

Materials and methods: We developed a novel release assay based on a millifluidic device. A 500?µm capillary tube was heated by a temperature-controlled Peltier element. A TSL solution encapsulating a fluorescent compound was pumped through the tube, producing a fluorescence gradient along the tube due to TSL release. Release kinetics were measured by analysing fluorescence images of the tube. We measured three TSL formulations: traditional TSL (DPPC:DSPC:DSPE-PEF2000,80:15:5), MSPC-LTSL (DPPC:MSPC:DSPE-PEG2000,85:10:5) and MPPC-LTSL (DPPC:MMPC:PEF2000,86:10:4). TSL were loaded with either carboxyfluorescein (CF), Calcein, tetramethylrhodamine (TMR) or doxorubicin (Dox). TSL were diluted in one of the four buffers: phosphate buffered saline (PBS), 10% bovine serum albumin (BSA) solution, foetal bovine serum (FBS) or human plasma. Release was measured between 37–45?°C.

Results: The millifluidic device allowed measurement of release kinetics within the first few seconds at ～5?ms temporal resolution. Dox had the fastest release and highest release %, followed by CF, Calcein and TMR. Of the four buffers, release was fastest in human plasma, followed by FBS, BSA and PBS.

Conclusions: The millifluidic device allows measurement of TSL release at unprecedented temporal resolution, thus allowing adequate characterisation of TSL release at time scales relevant for intravascular triggered drug release. The type of buffer and encapsulated compound significantly affect release kinetics and need to be considered when designing and evaluating novel TSL-drug combinations.     

The Accuracy of Digital Templating for Primary Total Hip Arthroplasty: Is There a Difference Between Direct Anterior and Posterior Approaches?

Background

The direct anterior approach (DAA) has gained recent popularity for total hip arthroplasty (THA), as it provides immediate feedback on cup position and limb length using fluoroscopy. The purpose of this study is to evaluate any differences in the accuracy of digital templating for preoperative planning of THA, performed with 2 different surgical approaches: DAA using a radiolucent table with intraoperative fluoroscopy and the posterior approach (PA).

Home Discharge After Primary Elective Total Joint Arthroplasty: Postdischarge Complication Timing and Risk Factor Analysis

Background

Bundled payment programs for primary total joint arthroplasty (TJA) have identified reducing nonhome discharge as a major area of cost savings. Health care providers must therefore identify, risk stratify, and appropriately care for home-discharged TJA patients. This study aimed to analyze risk factors and timing of postdischarge complications among home-discharged primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients and risk stratify them to identify those who would benefit from higher level care.

Advancement of deep learning in pneumonia/Covid‐19 classification and localization: A systematic review with qualitative and quantitative analysis

Around 450 million people are affected by pneumonia every year, which results in 2.5 million deaths. Coronavirus disease 2019 (Covid‐19) has also affected 181 million people, which led to 3.92 million casualties. The chances of death in both of these diseases can be significantly reduced if they are diagnosed early. However, the current methods of diagnosing pneumonia (complaints + chest X‐ray) and Covid‐19 (real‐time polymerase chain reaction) require the presence of expert radiologists and time, respectively. With the help of deep learning models, pneumonia and Covid‐19 can be detected instantly from chest X‐rays or computerized tomography (CT) scans. The process of diagnosing pneumonia/Covid‐19 can become faster and more widespread. In this paper, we aimed to elicit, explain, and evaluate qualitatively and quantitatively all advancements in deep learning methods aimed at detecting community‐acquired pneumonia, viral pneumonia, and Covid‐19 from images of chest X‐rays and CT scans. Being a systematic review, the focus of this paper lies in explaining various deep learning model architectures, which have either been modified or created from scratch for the task at hand. For each model, this paper answers the question of why the model is designed the way it is, the challenges that a particular model overcomes, and the tradeoffs that come with modifying a model to the required specifications. A grouped quantitative analysis of all models described in the paper is also provided to quantify the effectiveness of different models with a similar goal. Some tradeoffs cannot be quantified and, hence, they are mentioned explicitly in the qualitative analysis, which is done throughout the paper. By compiling and analyzing a large quantum of research details in one place with all the data sets, model architectures, and results, we aimed to provide a one‐stop solution to beginners and current researchers interested in this field.     

Long-term enhancement of botulinum toxin injections by upper-eyelid surgery in 14 patients with facial dyskinesias.

OBJECTIVES: To determine the effects of upper-eyelid surgery (limited myectomy, blepharoplasty, and levator aponeurotic advancement) on patients who demonstrated a suboptimal response or residual heaviness of the upper eyelids after botulinum toxin eyelid injections for facial dyskinesia. DESIGN: Retrospective study. SUBJECTS: Charts of 358 patients with a diagnosis of benign essential blepharospasm, Meige syndrome (with eyelid involvement), and hemifacial spasm were reviewed. METHODS: Data were retrospectively analyzed and included subjective and objective responses about botulinum toxin injections (number and duration of effect of injections before and after eyelid surgery). RESULTS: Of 358 patients with facial dyskinesias, 14 (3.91%) underwent upper-eyelid limited myectomy with or without upper-lid blepharoplasty (n = 5), upper-lid blepharoplasty alone (n = 6), or levator advancement with or without blepharoplasty (n = 3). Mean subjective improvement was 68.75% after limited myectomy combined with blepharoplasty and 58.33% after levator and/or blepharoplasty surgery. Average duration of effect of injections increased from 122.1 days in the patients prior to undergoing eyelid surgery to 210.5 days after surgery. CONCLUSIONS: Upper-eyelid surgery, including limited myectomy, enhanced the effect of the botulinum toxin in this small group of patients. Patients with a suboptimal response to injections in terms or moderate to marked dermatochalasis with subjective heaviness of the eyelids, upper-eyelid blepharoplasty, and/or limited myectomy should be considered.