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Background: We estimated trends for mortality after transcatheter aortic valve replacement (TAVR) using meta-analytic techniques. Mortality rates after TAVR have reportedly declined as the procedure became more routinized and device technology improved. Confirming this finding with a systematic assessment of the evidence could have substantial implications for the choice between TAVR and surgical valve replacements. Methods: We conducted a systematic literature review up to June 20, 2018 and extracted data on 30-day and 1-year mortality rates, surgical risk, device type, study design, and the proportion of procedures that used a transapical approach. We used meta-regression to test whether risk-adjusted 30-day and 1-year mortality rates declined over time. Results: We identified 145 studies and 179 subsamples, once results for separately reported subgroups were broken out. Of these, 160 subsamples (89%) representing 137 studies and 91,652 patients contained information on 30-day mortality, and 93 subsamples (52%) representing 84 studies and 40,765 patients information on 1-year mortality. The adjusted 30-day mortality rate after TAVR fell from 10.48% (95% CI 7.97–11.65%) in 2007 to 2.27% (95% CI 1.14–4.49%) in 2016, corresponding to a relative decrease of 78% over 10 years. The adjusted mortality rate within 1 year after TAVR was 30.24% (95% CI 24.53–36.65%) in 2007 and fell to 11.35% (95% CI 8.32–15.31%) in 2014, corresponding to a relative decrease of 63% over 8 years. Conclusions: The results suggest that near-term survival after TAVR has improved substantially within the short period after the procedure was introduced and support the increasing utilization of TAVR.

The impact of initiatives aimed at reducing time in untreated psychosis during early-stage schizophrenia will be unknown for many years. Thus, we simulate the effect of earlier treatment entry and better antipsychotic drug adherence on schizophrenia-related hospitalizations, receipt of disability benefits, competitive employment, and independent/family living over a ten-year horizon. We predict that earlier treatment entry reduces hospitalizations by 12.6–14.4% and benefit receipt by 7.0–8.5%, while increasing independent/family living by 41.5–46% and employment by 42–58%. We predict larger gains if a pro-adherence intervention is also used. Our findings suggest substantial benefits of timely and consistent early schizophrenia care.

The Centers for Medicare & Medicaid Services (CMS) recently launched its Quality Payment Program (QPP), which considerably changes the way physicians are paid under Medicare. There has been significant concern about the ability of small rural practices to successfully participate in the program. To address these concerns, RAND researchers conducted interviews with physicians in small rural practices on the initial implementation of the QPP in order to understand the flexibility provisions for small rural practices and to inform future federal rulemaking for the QPP. The findings suggest that small rural practices are struggling to participate in the QPP. Interviewees reported frustration with a lack of clarity of program details, requirements that appeared to be determined late and were subject to change, and the amount of effort needed to participate. Interviewees suggested several changes to the QPP and Medicare policy to improve the ability of small rural practices to participate in the program. These changes included clarifying and specifying program requirements, reducing the frequency of program policy changes, delaying program implementation for small practices, avoiding penalizing small practices that serve vulnerable populations, developing less obtrusive methods for assessing the quality of care of small practices, providing additional information technology support for small rural practices, and enabling greater engagement of rural physicians by policymakers.

Aim Duration of untreated psychosis in early schizophrenia impacts long-term outcomes. Because long-acting injectable (LAI) antipsychotic drugs improve adherence in early-stage patients, they could reduce additional time in uncontrolled psychosis (TUP) during the critical period of the illness. However, the long-term benefit of early LAI use over oral formulations has not been quantified. This study explores the potential magnitude of the benefit with a simulation approach. Methods A microsimulation models the effects of 11 treatment pathways reflecting alternative decisions on whether and when LAI agents are used during a "calibration phase" that starts at treatment entry and lasts until the end of the 3-year critical period. Treatment failure prolongs time in psychosis. Long-term outcomes are predicted over the ensuing 7-year period as a function of TUP. Results An "early LAI" pathway where LAI treatment follows the second oral treatment failure is compared to an oral-only pathway. Under these pathways, 69% and 46% of patients, respectively, are estimated to exit the calibration phase with adequate symptom control (total positive and negative syndrome scale score below 68). Relative to the oral-only pathway, the early LAI pathway is predicted to increase competitive employment by 39% (25% vs 18%) and independent or family living by 22% (71% vs 58%), and to decrease receipt of disability benefits by 36% (42% vs 66%) and hospital admissions per 1000 patient-years by 15% (249% vs 294%). Conclusions While these simulation results need to be confirmed empirically, they suggest that earlier use of LAI antipsychotics can meaningfully improve patient outcomes.

There is increasing concern over the common, repetitive forms of blast—often unrelated to combat—to which military members are exposed during service, and how those exposures could affect the central nervous system, potentially resulting in neurological and emotional consequences. The authors of this report review the relevant literature and identify research and policy gaps related to military occupational blast exposure.

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates that the Centers for Medicare & Medicaid Services (CMS) use standardized patient assessment data elements across post-acute care settings. RAND was tasked by CMS with developing and testing the data elements. This report, Volume 2 of a series, focuses on the design and methods for the National Beta Test.

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates that the Centers for Medicare & Medicaid Services (CMS) use standardized patient assessment data elements across post-acute care settings. CMS tasked RAND with developing and testing the data elements. This report, Volume 8 of a series, presents test data and interpretations of the results for data elements developed for non-communicative patients.

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates that the Centers for Medicare & Medicaid Services (CMS) use standardized patient assessment data elements across post-acute care settings. CMS tasked RAND with developing and testing the data elements. This report, Volume 7 of a series, presents test data and interpretations of the results for care preferences, medication reconciliation, and global health data elements.

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates that the Centers for Medicare & Medicaid Services (CMS) use standardized patient assessment data elements across post-acute care settings. RAND was tasked by CMS with developing and testing the data elements. This report, Volume 6 of a series, presents results for data elements in the categories of (1) impairments and (2) special services, treatments, and interventions.

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates that the Centers for Medicare & Medicaid Services (CMS) use standardized patient assessment data elements across post-acute care settings. RAND was tasked by CMS with developing and testing the data elements. This report, Volume 5 of a series, presents test data and interpretations of the results for data elements in the clinical categories of mental status and pain.

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates that the Centers for Medicare & Medicaid Services (CMS) use standardized patient assessment data elements across post-acute care settings. CMS tasked RAND with developing and testing the data elements. This report, Volume 4 of a series, presents quantitative and qualitative data gathered during testing and interpretations of the results for cognitive status data elements.

Physician practice engagement with alternative payment models (APMs) would be enhanced by simpler APMs, a slower pace of change, greater support for new capabilities and timely data, and reexamination of practice response to APMs with financial risk.

This study, sponsored by the American Medical Association (AMA), describes how alternative payment models (APMs) affect physicians, physicians' practices, and hospital systems in the United States and also provides updated data to the original 2014 study. Payment models discussed are core payment (fee for service, capitation, episode-based and bundled), supplementary payment (shared savings, pay for performance, retainer-based), and combined payment (medical homes and accountable care organizations). The effects of changes since 2014 in the Affordable Care Act (ACA) and of new alternative payment models (APMs), such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP), are also examined. This project uses the same qualitative multiple–case study method as the 2014 study, relying primarily on semistructured interviews with physician practice leaders, physicians, and other observers. Findings describe the challenges posed by APMs, strategies adopted to deal with APMs, the effects of rapidly changing and increasingly complex payment models, and how risk aversion influences physician practices' decisions to engage in new payment models. Project findings are intended to help guide efforts by the AMA and other stakeholders to improve current and future APMs and help physician practices succeed in them.

Anecdotal evidence suggests that risk-adjusted mortality rates after TAVR have been declining over the years as the procedure became more routinized and device technology improved. Confirming this finding with a systematic assessment of the evidence could have substantial implications for the choice

In this article, the authors explore why medical device innovation has traditionally been geared so thoroughly toward improving performance, with little regard to cost. They argue that the changing incentives in the health care sector and the move to value-based payment models, accelerated by the implementation of the Affordable Care Act, will force device manufacturers to redirect investments from the spectacular toward the prudent, which they dub “the end of sexy.” The authors explore consequences for manufacturers, investors, and policymakers.

Spumellarian radiolarians are abundant within lower Silurian concretions that also contain an exceptionally-preserved, non-biomineralized, three-dimensional macrofauna (the Herefordshire Konservat-Lagerstatte). Only the radiolarian tests are preserved; sparry calcite precipitated in the space originally occupied by the cytoplasm. Partial dissolution of the tests occurred during precipitation of the calcite, but more significant, later dissolution created voids that are now infilled by ankerite and clay minerals. Specimens are surrounded by spherical 'cocoons' of quartz, kaolinite, pyrite and, especially, ankerite, the last a product of secondary dolomitization of the sparry calcite. Although there are strong parallels with the taphonomy of the most common element of the macrofauna, the non-biomineralized arthropod Offacohis kingi, uncertainties remain as to the relative timing of the precipitation and/or accumulation of clay minerals that are associated with both taxa. The unusual preservation of radiolarian tests in carbonate minerals impacts negatively on the quality and abundance of specimens recovered using standard micropalaeontological bulk- processing techniques; modified techniques yield a higher number of complete specimens.