Citations

Introduction The Centers for Medicare & Medicaid skilled nursing facility (SNF) 3-day waiver permits patients attributed to an Accountable Care Organization (ACO) to be admitted to an SNF or transitional care unit from an emergency department, outpatient setting, inpatient stay (<3 days), or observational status without Medicare’s requisite 3-day inpatient stay. Methods Our institution’s ACO implemented the waiver program in 2023. We report our experience with implementing the waiver and describe benefits and barriers, as well as interventions developed, outcomes achieved, and opportunities presented for patients and health care facilities. Results Through a streamlined process, patients can more readily access essential care, and health care facilities benefit from enhanced efficiency. Furthermore, the ACO can more effectively manage health care utilization and cost. Although the program offers benefits to patients, their families, and health care facilities, implementing and maintaining the program has challenges, with barriers including underdeveloped workflows, gaps in staff education and communication, difficulties in patient identification, and challenges with specific facility requirements. Conclusions The SNF 3-day rule waiver has been valuable in enhancing patient care and optimizing health care delivery within our ACO. Ongoing efforts to refine processes and address challenges will further improve the program’s effectiveness and sustainability.

Abstract The environmental impact of computer-aided diagnosis (CADx) in colonoscopy is unknown. The potential to reduce greenhouse gas emissions by limiting unnecessary polypectomies may be offset by emissions associated with CADx devices. We quantified and compared the carbon footprint of colonoscopy with and without CADx. Life-cycle carbon emissions associated with endoscopic snares, polyp traps, histopathology, and CADx devices were estimated using life-cycle assessment software. The effect of CADx was estimated by the carbon dioxide equivalent (CO2e) emissions related to outcomes from a prospective cohort of patients who underwent colonoscopy with optical diagnosis under a leave-in-situ strategy (i.e. rectosigmoid polyps ≤5 mm predicted as non-neoplastic were not removed) with and without CADx assistance. We analyzed 1134 individuals (median age 67 years, 59% male) with 1716 colorectal polyps. Colonoscopy with CADx reduced the number of snares and polyp traps from 567 to 543 (difference: 24) and histopathology submissions from 1343 to 1278 (difference: 65). However, the total carbon footprint increased from 832 kg CO2e (95%CI 815 to 847) without CADx to 946 kg CO2e (95%CI 927 to 965) with CADx, corresponding to an absolute increase of 114 kg CO2e (95%CI 80 to 150) or 0.10 kg CO2e per colonoscopy. Using CADx under a leave-in-situ strategy increased the environmental burden of colonoscopy.