Departments of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
Departments of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.
JAMA Intern Med. 2018 May 1;178(5):648-654. doi: 10.1001/jamainternmed.2017.8087.
Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown.
To determine whether Medicare Shared Savings Program (MSSP) ACO enrollment changes the appropriateness of screening for breast, colorectal, and prostate cancers.
DESIGN, SETTING, AND PARTICIPANTS: For this population-based analysis of Medicare beneficiaries, we used Medicare data from 2007 through 2014 and evaluated changes in screening associated with ACO enrollment using differences-in-differences (DD) analyses. We then performed difference-in-difference-in-differences (DDD) analyses to determine whether observed changes in cancer screening associated with ACO enrollment were different across strata of appropriateness, defined using age (65-74 years vs ≥75 years) and predicted survival (top vs bottom quartile).
Rates of breast, colorectal, and prostate cancer screening measured yearly as a proportion of eligible Medicare beneficiaries undergoing relevant screening services.
Among Medicare beneficiaries, comprising 39 218 652 person-years before MSSP enrollment and 17 252 345 person-years after MSSP enrollment, breast cancer screening declined among both ACO (42.7% precontract, 38.1% postcontract) and non-ACO (37.3% precontract, 34.1% postcontract) populations. The adjusted rate of decline (DD) in the ACO population exceeded the non-ACO population by 0.79% (P < .001). This decline was most pronounced among elderly women (-2.1%), with minimal observed change among younger women (-0.26%). Baseline colorectal cancer screening rates were lower than those for breast cancer among both ACO (10.1% precontract, 10.3% postcontract) and non-ACO (9.2% precontract, 9.1% postcontract) populations. We observed an adjusted 0.24% (P = .03) increase in screening associated with ACO enrollment, most pronounced among younger Medicare beneficiaries (0.36%). For breast and colorectal cancer, we observed statistically significant differences in estimates of effect between age strata, suggesting that the ACO effect on cancer screening is mediated by age (DDD for both P < .001). Prostate cancer screening declined among ACO (35.1% precontract, 28.5% postcontract) and non-ACO (31.2% precontract, 25.7% postcontract) populations. The adjusted rate of decline in the ACO population exceeded that of the non-ACO population by 1.2%. We observed no difference in estimate of effect between age strata, suggesting that the ACO-mediated changes in prostate cancer screening are similar among younger and elderly men. Results characterizing appropriateness with predicted survival mirrored those when stratified by age.
Medicare Shared Savings Program ACO enrollment is associated with more appropriate breast and colorectal screening, although the magnitude of the observed ACO effect is modest in the early ACO experience.
尽管问责制医疗保健组织 (ACO) 迅速扩散，但 ACO 注册是否会导致癌症筛查发生可观察到的变化仍不得而知。
确定医疗保险储蓄计划 (MSSP) ACO 注册是否会改变乳腺癌、结直肠癌和前列腺癌的筛查适宜性。
设计、设置和参与者：在这项基于人群的医疗保险受益人的分析中，我们使用了 2007 年至 2014 年的医疗保险数据，并使用差异分析 (DD) 分析来评估与 ACO 注册相关的筛查变化。然后，我们进行了差异差异差异分析 (DDD)，以确定与 ACO 注册相关的癌症筛查的观察到的变化是否因适宜性的分层而不同，适宜性是使用年龄 (65-74 岁与 ≥75 岁) 和预测生存率 (前四分之一与后四分之一) 来定义的。
每年以接受相关筛查服务的符合条件的医疗保险受益人的比例衡量的乳腺癌、结直肠癌和前列腺癌筛查率。
在医疗保险受益人中，在 MSSP 注册之前包括 39218652 人年，在 MSSP 注册之后包括 17252345 人年，乳腺癌筛查在 ACO (42.7%签约前，38.1%签约后) 和非 ACO (37.3%签约前，34.1%签约后) 人群中均下降。ACO 人群中的调整后下降率 (DD) 比非 ACO 人群高 0.79%（P<0.001）。这种下降在老年女性中最为明显（-2.1%），年轻女性中观察到的变化最小（-0.26%）。结直肠癌筛查的基线率低于 ACO（签约前 10.1%，签约后 10.3%）和非 ACO（签约前 9.2%，签约后 9.1%）人群中的乳腺癌筛查率。我们观察到与 ACO 注册相关的筛查有 0.24%（P=0.03）的调整后增加，在较年轻的医疗保险受益人中最为明显（0.36%）。对于乳腺癌和结直肠癌，我们观察到在年龄分层方面，效果估计值存在统计学显著差异，这表明 ACO 对癌症筛查的影响是通过年龄介导的（两者的 DDD<0.001）。前列腺癌筛查在 ACO（签约前 35.1%，签约后 28.5%）和非 ACO（签约前 31.2%，签约后 25.7%）人群中均下降。ACO 人群的调整下降率高于非 ACO 人群 1.2%。我们在年龄分层方面没有观察到效果估计值的差异，这表明 ACO 介导的前列腺癌筛查变化在年轻和老年男性中相似。以预测生存率为特征的适宜性结果反映了按年龄分层的结果。
医疗保险储蓄计划 ACO 注册与更适宜的乳腺癌和结直肠癌筛查相关，尽管在早期 ACO 经验中观察到的 ACO 效果幅度较小。
