{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T22:56:55Z","timestamp":1787871415804,"version":"build-2784847793"},"reference-count":29,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"9","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Circ: Cardiovascular Quality and Outcomes"],"published-print":{"date-parts":[[2022,9]]},"abstract":"<jats:sec>\n            <jats:title>Background:<\/jats:title>\n            <jats:p>Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods:<\/jats:title>\n            <jats:p>Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results:<\/jats:title>\n            <jats:p>The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (\u03b2=16032.5, p=0.008).<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions:<\/jats:title>\n            <jats:p>Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/circoutcomes.121.008592","type":"journal-article","created":{"date-parts":[[2022,9,6]],"date-time":"2022-09-06T09:00:18Z","timestamp":1662454818000},"update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":6,"title":["Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care\u2013Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset"],"prefix":"10.1161","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5718-6545","authenticated-orcid":true,"given":"K. Dennie","family":"Kim","sequence":"first","affiliation":[{"name":"Strategy, Ethics, and Entrepreneurship, Darden School of Business, University of Virginia, Charlottesville (K.D.K.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Russell J.","family":"Funk","sequence":"additional","affiliation":[{"name":"Department of Strategic Management and Entrepreneurship, Carlson School of Management, University of Minnesota, Minneapolis (R.J.F.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0890-0746","authenticated-orcid":true,"given":"Hechuan","family":"Hou","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, Michigan Medicine (H.H., F.D.P., L.C., D.S.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Austin","family":"Airhart","sequence":"additional","affiliation":[{"name":"University of Michigan Medical School, Ann Arbor (A.A., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9607-8037","authenticated-orcid":true,"given":"Khalil","family":"Nassar","sequence":"additional","affiliation":[{"name":"University Hospital, Michigan Medicine (K.N.), University of Michigan, Ann Arbor."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4430-9969","authenticated-orcid":true,"given":"Francis D.","family":"Pagani","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, Michigan Medicine (H.H., F.D.P., L.C., D.S.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Min","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor (M.Z.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P. Paul","family":"Chandanabhumma","sequence":"additional","affiliation":[{"name":"Mixed Methods Program, Department of Family Medicine (P.P.C.), University of Michigan, Ann Arbor."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1538-576X","authenticated-orcid":true,"given":"Keith D.","family":"Aaronson","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine (K.D.A.), University of Michigan, Ann Arbor."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3211-0509","authenticated-orcid":true,"given":"Carol E.","family":"Chenoweth","sequence":"additional","affiliation":[{"name":"Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine (C.E.C.), University of Michigan, Ann Arbor."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8897-8932","authenticated-orcid":true,"given":"Ahmad","family":"Hider","sequence":"additional","affiliation":[{"name":"University of Michigan Medical School, Ann Arbor (A.A., A.H.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lourdes","family":"Cabrera","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, Michigan Medicine (H.H., F.D.P., L.C., D.S.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0416-9359","authenticated-orcid":true,"given":"Donald S.","family":"Likosky","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, Michigan Medicine (H.H., F.D.P., L.C., D.S.L.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"on behalf of the Michigan Congestive Heart Failure Investigators","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1900486"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1097\/MAT.0000000000001287"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jtcvs.2021.04.074"},{"key":"e_1_3_3_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcrc.2019.12.014"},{"key":"e_1_3_3_6_2","doi-asserted-by":"publisher","DOI":"10.1097\/MLR.0b013e31822dcef7"},{"key":"e_1_3_3_7_2","article-title":"Care Fragmentation Predicts 90-Day Durable Ventricular Assist Device Outcomes","author":"Funk RJ","unstructured":"Funk, RJ, Pagani, FD, Hou, H, Zhang, M, Yang, G, Malani, PN, Chandanabhumma, PP, Cabrera, L, Kim, KD, Likosky, DS. 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