An opinionated take on NEJM highlights for September 2018


Primary care organizations are better ACOs when it comes to achieving savings

Initial results from the Medicare Shared Savings Program ACO have been disappointing pointing to small to negligible net effects on net spending, but a clever analysis digging into the details shows that there is a silver lining. The key insight is to distinguish between ACOs that are health systems and those that are physician practice groups: health systems show no net savings (after bonus incentive payments) while physician group ACOs do. In the physician group ACOs, the savings are driven in roughly equal measure by inpatient care, post-acute care, and ambulatory care at hospital owned-facilities. Thinking about incentives this makes perfect sense: a health system needs to feed its fixed asset/cost base (aka hospitals) and it is very hard for the Chief Financial Officer and the Chief Population Health Officer to come to an agreement on what bed occupancy should be.  Meanwhile, a physician group ACO operates upstream of all this, and does not suffer reverse incentives from lowering utilization of hospital based facility, especially now that the whole concept of admitting privileges and rounding on your patients in the hospital is pretty much gone. How will health systems figure this out? Not clear, but Optum Health is smiling. Medicare Spending after 3 Years of the Medicare Shared Savings Program (subscriber access)


New hope in spinal cord injury

In the US alone, more than a million individuals live with the reality that complete persistent loss of motor function after spinal injury is not reversible. There may be some hope for improvement after all. In a report about 4 consecutive patients treated at the University of Louisville, implantation of an electrode array in the lower spine together with appropriately tailored stimulation enabled all the patients to stand (while holding onto something for equilibrium) and two of the patients to walk over ground (again with assistance for equilibrium). Interestingly, the stimulation was not “robotic” in the sense of a sequential activation of specific muscles, but rather triggering of the neural networks within the spinal cord that regulate walking.  Even limited progress is of tremendous value for individuals suffering from these deficits, but a caveat is that it clearly took an immense amount of customized effort to get there. Hopefully there will be some more standard efficient pathways developed as this research matures. Recovery of Over-Ground Walking after Chronic Motor Complete Spinal Cord Injury (subscriber access)


A medical mystery

Patients with heart failure often have mitral valve regurgitation (i.e. when the left ventricle contracts, there is backflow of blood into the atrium instead of all the blood getting pumped forward into the systemic circulation), and conversely, patients with significant mitral valve regurgitation frequently go into heart failure. It is a vicious cycle which is hard to get out of for those patients not healthy enough to undergo open-heart surgery for valve replacement. Enter Mitra-Clip (Abbott), a device introduced through the heart (but without cracking the chest) that mitigates the lack of closure of the mitral valve during contractions of the heart by “clipping together” valvular leaflets. In principle, it’s great because it can be delivered through a relatively light procedure but what is the evidence of clinical benefit? Now come two randomized controlled studies comparing Mitra-Clip with best non-surgical management, one conducted in France with ~150 patients in each arm, the other conducted in the US with ~300 patients in each arm and they show different results: no benefit in the French study, a marked benefit including mortality in the US study.  On their face, both studies look solid, with the length of the study as the only notable difference (France 12 vs. 24 months US). Unfortunately they do not always report on the same metrics so it is hard to pin-point what is driving the difference. At first blush, it seems like the US rate of hospitalization in the placebo group was significantly higher than for the French placebo. Does that mean a difference in underlying population or practice? That’s unclear. But if there was ever an argument for making granular, raw trial data available for analysis by third parties, this is the case. We might learn a lot about this type of heart failure AND differences in effectiveness of health care systems in dealing with it.  Transcatheter Mitral-Valve Repair in Patients with Heart Failure; Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation (free access)


The New England Journal of Medicine is a premier weekly medical journal covering many topics of interest to the health sector. In this monthly series we offer an opinionated perspective on selected highlights that might be of interest to our clients and others.