Objectives The COMPASS (COMprehensive Post-Acute Stroke Services) pragmatic trial cluster-randomized 40 hospitals in North Carolina to the COMPASS transitional care (TC) postacute care intervention or usual care. We estimated the difference in healthcare expenditures postdischarge for patients enrolled in the COMPASS-TC model of care compared with usual care. Methods We linked data for patients with stroke or transient ischemic attack enrolled in the COMPASS trial with administrative claims from Medicare fee-for-service (n = 2262), Medicaid (n = 341), and a large private insurer (n = 234). The primary outcome was 90-day total expenditures, analyzed separately by payer. Secondary outcomes were total expenditures 30- and 365-days postdischarge and, among Medicare beneficiaries, expenditures by point of service. In addition to intent-to-treat analysis, we conducted a per-protocol analysis to compare Medicare patients who received the intervention with those who did not, using randomization status as an instrumental variable. Results We found no statistically significant difference in total 90-day postacute expenditures between intervention and usual care; the results were consistent across payers. Medicare beneficiaries enrolled in the COMPASS intervention arm had higher 90-day hospital readmission expenditures ($682, 95% CI $60-$1305), 30-day emergency department expenditures ($132, 95% CI $13-$252), and 30-day ambulatory care expenditures ($67, 95% CI $38-$96) compared with usual care. The per-protocol analysis did not yield a significant difference in 90-day postacute care expenditures for Medicare COMPASS patients. Conclusions The COMPASS-TC model did not significantly change patients’ total healthcare expenditures for up to 1 year postdischarge.

Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.

There was substantial urban–rural depression disparity in elderly Chinese. Social support was significantly associated with elderly depression in China. Urban–rural gap in community support largely contributed to depression disparity. Community support for rural elderly should be strengthened.

In the transition to value-based care, several alternative payment models (APM) have been developed to provide financial incentives for providers to deliver coordinated, high-quality care at lower costs. The Medicare Shared Savings Program (MSSP) is by far the largest voluntary APM in Medicare and continues to play a significant role in moving away from traditional fee-for-service incentives. However, evaluating the causal effect of the MSSP is challenging in the presence of practice interactions. Practices may be more likely to participate and perform well in the MSSP when their peer practices, with whom they share a lot of patients, engage in similar efforts. Practice interactions also likely provide channels for the effects of MSSP to extend to non-MSSP beneficiaries. Little is known about the role of practice interactions in the participation and outcomes of the MSSP. The overall objective of this study is to leverage a network analytic approach based on patient sharing patterns across practices, combined with quasi-experimental designs, to examine the relationships between peer participation, spillover effects, and the performance of the MSSP. In Aim 1, I estimate the magnitude of peer effects in MSSP participation. In Aim 2, I examine whether peer participation modifies the effect of ACO on beneficiary-level outcomes. In Aim 3, I leverage patient geographic migration to estimate the effect of market-level MSSP penetration on non-MSSP beneficiaries’ outcomes. Results from this study show that at the practice level, more peers participating in the MSSP increase the probability of an index practice participating in the program. At the beneficiary level, the effect of ACO on cost savings is more pronounced for beneficiaries attributed to the primary care practices with higher peer ACO participation rates. At the market level, we find evidence of spillover effects on outpatient service utilization, and the direction of spillover effects depends on outpatient care settings. These findings suggest peer effects are an important mechanism aligning voluntary participation across practices and can be better leveraged to achieve cost savings and better patient outcomes under the MSSP. The evidence of spillover effects suggests that the MSSP-induced change in outpatient care patterns has extended to non-MSSP beneficiaries.

We provide novel empirical evidence of market-level spillover effects of MSSP on non-MSSP beneficiaries by leveraging a plausibly exogenous source of variation in the MSSP penetration rate triggered by non-MSSP beneficiaries moving across hospital referral regions. The different directions of estimated spillover effects on hospital outpatient and E&M utilization may suggest that the MSSP-induced systematic change in care patterns has extended to non-MSSP beneficiaries.

Peer effects are an important mechanism influencing practice selection into the Medicare Shared Savings Program. The role of peer effects in aligning voluntary participation across practices may have implications for other value-based care models.