Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose

Importance

Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking.

Objective

To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization.

Design, Setting, and Participants

This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023.

Exposure

Hospital OORP implementation.

Main Outcomes and Measures

The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access.

Results

A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities.

Conclusions and Relevance

In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

Promote to protect: data-driven computational model of peer influence for vaccine perception

Vaccine hesitancy and acceptance, driven by social influence, is usually explored by most researchers using exhaustive survey-based studies, which investigate public preferences, fundamental values, beliefs, barriers, and drivers through closed or open-ended questionnaires. Commonly used simple statistical tools do not do justice to the richness of this data. Considering the gradual development of vaccine acceptance in a society driven by multiple local/global factors as a compartmental contagion process, we propose a novel methodology where drivers and barriers of these dynamics are detected from survey participants' responses, instead of heuristic arguments. Applying rigorous natural language processing analysis to the survey responses of participants from India, who are from various socio-demographics, education, and perceptions, we identify and categorize the most important factors as well as interactions among people of different perspectives on COVID-19 vaccines. With a goal to achieve improvement in vaccine perception, we also analyze the resultant behavioral transitions through platforms of unsupervised machine learning and natural language processing to derive a compartmental contagion model from the data. Analysis of the model shows that positive peer influence plays a very important role and causes a bifurcation in the system that reflects threshold-sensitive dynamics.

Commentary: Determining Economic Factors That Matter to People With Intellectual and Developmental Disabilities and Their Caregivers: A Process Framework

BACKGROUND

The 2020-2029 strategic plan for the Patient-Centered Outcomes Research Trust Fund calls for addressing data infrastructure gaps that are critical for studying issues around intellectual and developmental disabilities (I/DD). Specifically, the plan calls for data collection on economic factors that affect person-centered approaches to health care decision-making. Among people with I/DD and their caregivers, such economic factors may include financial costs of care, decreased opportunities for leisure and recreation, income losses associated with caregiving, and foregone opportunities for skill acquisition or other human capital investments.

OBJECTIVE

This commentary supports responsiveness to the Patient-Centered OutcomesResearch Trust Fund (PCORTF) calls by conceptualizing and operationalizing a framework for identifying preferences on economic factors that are relevant to people with I/DD and their caregivers.

MAIN ARGUMENTS

The framework outlined in this commentary addresses barriers to data collection that hinder measure development in the study of I/DD. This work is significant and timely given the continued movement to integrate and maintain people with I/DD within communities and recent methodological advances for eliciting preferences among people with I/DD.

RELEVANCE TO THE SPECIAL ISSUE

Readers will be introduced to a framework for building data capacity in the study of economic outcomes among a population that is a high research priority for federal funding agencies. This commentary aims to be useful to researchers in planning, developing, and initiating projects in this area.

Double Jab: Survey Evidence on Vaccine Hesitancy, Beliefs, and Attitudes in India

India witnessed a large surge in COVID-19 cases in April 2021, a second wave of nearly 350,000 daily new infections across the country. As of December 2021, cases have reduced drastically, in part due to greater vaccine coverage across the country. This study reports results on vaccine hesitancy, attitudes, and behaviors from an online survey conducted between February and March 2021 in nine Indian cities (N = 518). We find that vaccine hesitancy negatively predicts willingness to take the vaccine, and beliefs about vaccine effectiveness supersede hesitancy in explaining vaccine uptake. Furthermore, we find that mask-wearing and handwashing beliefs, information sources related to COVID-19, and past COVID-19 infection and testing status are all strongly associated with the hypothetical choice of vaccine. We discuss these findings in the context of behavioral theories as well as outline implications for vaccine-related health communication in India.

No going back: COVID-19 disease threat perception and male migrants' willingness to return to work in India

This paper explores the causal link between the likelihood of re-migration to cities and the perceived threat of contracting COVID-19 using novel data on male reverse migrant workers in India. We find that reverse-migrants who believe there is a significant chance of contracting COVID-19 display a significantly lower likelihood of returning to their urban workplaces, regardless of their duration of migration. On the other hand, longer-duration migrants display a lower perceived chance of contracting COVID-19 than shorter-duration migrants. We also contribute to the migration literature by linking behavioural attributes to the decision to migrate. We find that more impatient individuals display a heightened belief regarding contracting COVID-19 and a higher projected likelihood of returning to work. Finally, we find that while both loss and risk-averse individuals have a lower projected likelihood of returning to urban workplaces, only loss-averse individuals perceive that their chance of contracting COVID-19 is lower.

Effect of Eased Restrictions for Aca-Exempt Short-Term Health Plans on Marketplace Premiums and Uninsured Rate: A Difference in Differences Analysis

The Affordable Care Act (ACA) established broad standards for private health insurance in the United States including requiring minimum essential benefits and prohibiting medical underwriting, but the law also permitted some exceptions. This paper examines one type of exempt plan option, Short-Term, Limited Duration Insurance (STLDI) that is not required to fully meet ACA benefit and underwriting standards. Federal rules governing STLDI plans have changed over time, with more permissive rules in the Trump administration allowing individuals to remain covered for longer durations of time relative to the original Obama regulations. Within applicable federal guidelines, states have also varied STLDI rules. Using publicly available data measuring state-level variations in STLDI regulations, ACA benchmark premiums, uninsured rates, and population characteristics for 2014 to 2021, we estimate difference-in-differences models to examine if more permissible STLDI policies are associated with higher premiums in the fully regulated non-group market and, also, lower uninsured rates. We find that longer duration, more permissible STLDI is associated with higher benchmark premiums in ACA exchanges and no difference in state-level uninsured rates. Trump administration regulations permitting longer duration STLDI plans to make available more affordable ACA-exempt health insurance were associated with higher premium costs in the ACA-regulated non-group market but we did not observe measurable impact on state uninsured rates. While longer-duration STLDI plans may result in lower costs for some, they have negative consequences for others requiring comprehensive coverage with no discernible benefit in overall coverage rates. Understanding these tradeoffs can help guide future policies regarding exceptions to ACA plan requirements.

Racial And Ethnic Disparities In Preventable Hospitalizations And ED Visits Five Years After ACA Medicaid Expansions

Medicaid expansions under the Affordable Care Act (ACA) dramatically increased access to insurance coverage. We examined whether the 2014 ACA Medicaid expansions also mitigated existing racial or ethnic disparities in preventable hospitalizations and emergency department (ED) visits. Using inpatient data from twenty-nine states and ED data from twenty-six states for the period 2011-18, we found that Medicaid expansions decreased disparities in preventable hospitalizations and ED visits between non-Hispanic Black and White nonelderly adults by 10 percent or more. There were no significant effects on disparities between Hispanic and non-Hispanic White nonelderly adults, possibly reflecting lower baseline differences and, separately, persisting coverage disparities. These findings highlight sustained improvements in community-level care for non-Hispanic Black populations, who historically lack access to care. Our findings also suggest access barriers experienced by Hispanic adults that need to be addressed beyond Medicaid eligibility expansion.

The Impact of Payment Reforms on the Safety Net: Examining Effects of the New Jersey Delivery System Reform Incentive Payment Program on Quality of Care Among Medicaid Beneficiaries

The Medicaid Delivery System Reform Incentive Payment (DSRIP) program has been among the most widely adopted value-based payment strategies to drive improved population health management among safety net populations. Using comprehensive claims data from New Jersey and difference-in-differences modeling, the authors examine the impact of DSRIP pay-for-performance disease management programs on outcomes related to targeted chronic conditions. The authors find DSRIP reduced asthma hospitalizations and emergency department visits, pneumonia readmissions, and improved alcohol and drug treatment. Positive program-specific findings are encouraging for future DSRIP-like initiatives and demonstrate provider ability to successfully adapt to payment reforms.

Impact of a Provider Tele-mentoring Learning Model on the Care of Medicaid-enrolled Patients With Diabetes

BACKGROUND

Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring program for health care providers, has been shown to improve provider-reported outcomes, but there is insufficient research on patient-level outcomes.

OBJECTIVES

To evaluate the impact of primary care provider (PCP) participation in Project ECHO on the care of Medicaid enrollees with diabetes.

RESEARCH DESIGN

New Jersey Medicaid claims and encounter data and difference-in-differences models were used to compare utilization and spending between Medicaid patients seen by PCPs participating in a Project ECHO program to those of matched nonparticipating PCPs.

SUBJECTS

A total of 1776 adult Medicaid beneficiaries (318 with diabetes), attributed to 25 participating PCPs; and 9126 total (1454 diabetic) beneficiaries attributed to 119 nonparticipating PCPs.

MEASURES

Utilization and spending for total inpatient, diabetes-related inpatient, emergency department, primary care, and endocrinologist services; utilization of hemoglobin A1c tests, eye exams, and diabetes prescription medications among diabetics, and total Medicaid spending.

RESULTS

Participation in Project ECHO was associated with decreases of 44.3% in inpatient admissions (P=0.001) and 61.9% in inpatient spending (P=0.021) among treatment relative to comparison patients. Signs of most other outcome estimates were consistent with hypothesized program effects but without statistical significance. Sensitivity analyses largely confirmed these findings.

CONCLUSIONS

We find evidence that Project ECHO participation was associated with large and statistically significant reductions of inpatient hospitalization and spending. The study was observational and limited by a small sample of participating PCPs. This study demonstrates the feasibility and potential value of quasi-experimental evaluation of Project ECHO patient outcomes using claims data.

Experimental evidence of the effect of financial incentives and detection on dishonesty

We revisit two fundamental motivations of dishonesty: financial incentives and probability of detection. We use an ability-based real effort task in which participants who are college students in India can cheat by over reporting the number of puzzles they could solve in a given period of time. The puzzles are all unsolvable and this fact is unknown to participants. This design feature allows us to obtain the distribution of cheating outcomes at the individual level. Controlling for participant attributes, we find that introducing piece-rate financial incentives lowers both the likelihood and magnitude of cheating only for individuals with a positive probability of detection. On the other hand, a decrease in the probability of detection to zero increases magnitude of cheating only for individuals receiving piece-rate incentives. Moreover, we observe that participants cheat significantly even in the absence of piece-rate incentives indicating that affective benefits may determine cheating. Finally, an increase in own perceived wealth status vis-à-vis one’s peers is associated with a higher likelihood of cheating while feeling more satisfied with one’s current economic state is associated with a lower magnitude of cheating.

A Culture-Centered Approach to Experiences of the Coronavirus Pandemic Lockdown Among Internal Migrants in India

India's coronavirus lockdown forced low-wage migrant workers to return from the city to the home towns and villages from which they came. Pre-pandemic living and working conditions were already stressful and difficult for these migrants. The lockdown became an additional burden, since it shut down sources of income with no assurance about when, or if, work and earning to support families could be resumed. This article draws on the lens of the Culture-Centered Approach (CCA) to understand how workers engaged with and navigated these difficult times. A total of 54 migrant workers locked-down at home across the Indian states of Bihar, Uttar Pradesh, and West Bengal were interviewed for this qualitative study. Financial worries were found to be endemic, with rising debt a major source of stress, and educational qualifications becoming an obstacle to earning. Returning migrants were suspected of bringing the virus from the city, and so stigmatized in their home towns and villages. However, the pandemic lockdown also showed some unexpected healthful consequences. It provided these marginalized, and always busy workers the time and space to stop working for a while, to stay home, eat home food, and take walks in the comparatively green and clean spaces of their home environments. In this, the pandemic lockdown may be seen to have enabled a measure of agency and health in the lives of these workers, an oasis albeit temporary, and ultimately subject to the demands of the globalized cities of India.

Defect induced ferromagnetic ordering and room temperature negative magnetoresistance in MoTeP

The magneto-transport, magnetization and theoretical electronic-structure have been investigated on type-II Weyl semimetallic MoTeP. The ferromagnetic ordering is observed in the studied sample and it has been shown that the observed magnetic ordering is due to the defect states. It has also been demonstrated that the presence of ferromagnetic ordering in effect suppresses the magnetoresistance (MR) significantly. Interestingly, a change-over from positive to negative MR is observed at higher temperature which has been attributed to the dominance of spin scattering suppression.

Effects of Permanent Supportive Housing on Health Care Utilization and Spending Among New Jersey Medicaid Enrollees Experiencing Homelessness

BACKGROUND

Permanent supportive housing (PSH) programs have the potential to improve health and reduce Medicaid expenditures for beneficiaries experiencing homelessness. However, most research on PSH has been limited to small samples of narrowly defined populations.

OBJECTIVE

To evaluate the effects of PSH on Medicaid enrollees across New Jersey.

RESEARCH DESIGN

Linked data from the Medicaid Management Information System and the Homeless Management Information System were used to compare PSH-placed Medicaid enrollees with a matched sample of other Medicaid enrollees experiencing homelessness. Comparisons of Medicaid-financed health care utilization and spending measures were made in a difference-in-differences framework 6 quarters before and after PSH placement.

SUBJECTS

A total of 1442 Medicaid beneficiaries enrolled in PSH and 6064 Medicaid-enrolled homeless individuals not in PSH in 2013-2014.

RESULTS

PSH placement is associated with a 14.3% reduction in emergency department visits (P<0.001) and a 25.2% reduction in associated spending (P<0.001). PSH also appears to reduce inpatient utilization and increase pharmacy spending with neutral effects on primary care visits and total costs of care (TCOC).

CONCLUSIONS

Placement in PSH is associated with lower hospital utilization and spending. No relationship was found, however, between PSH placement and TCOC, likely due to increased pharmacy spending in the PSH group. Greater access to prescription drugs may have improved the health of PSH-placed individuals in a way that reduced hospital episodes with neutral effects on TCOC.

Assessing resilience of healthcare infrastructure exposed to COVID-19: emerging risks, resilience indicators, interdependencies and international standards

In the moment of preparation of this paper, the world is still globally in grip of the Corona (COVID-19) crisis, and the need to understand the broader overall framework of the crisis increases. As in similar cases in the past, also with this one, the main interest is on the “first response”. Fully appreciating the efforts of those risking their lives facing pandemics, this paper tries to identify the main elements of the larger, possibly global, framework, supported by international standards, needed to deal with new (emerging) risks resulting from threats like Corona and assess the resilience of systems affected. The paper proposes that future solutions should include a number of new elements, related to both risk and resilience. That should include broadening the scope of attention, currently focused onto preparation and response phases, to the phases of “understanding risks”, including emerging risks, and transformation and adaptation. The paper suggests to use resilience indicators in this process. The proposed approach has been applied in different cases involving critical infrastructures in Europe (energy supply, water supply, transportation, etc., exposed to various threats), including the health system in Austria. The detailed, indicator-based, resilience analysis included mapping resilience, resilience stress-testing, visualization, etc., showing, already before the COVID-19, the resilience (stress-testing) limits of the infrastructures. A simpler (57 indicator based) analysis has, then been done for 11 countries (including Austria). The paper links these results with the options available in the area of policies, standards, guidelines and tools (such as the RiskRadar), with focus on interdependencies and global standards—especially the new ISO 31,050, linking emerging risks and resilience.

Did the Medicare Prescription Drug Program Lead to New Racial and Ethnic Disparities? Examining Long-term Changes in Prescription Drug Access among Minority Populations

This study examined whether the Medicare Part D program was associated with racial/ethnic disparities in prescription drug access among elderly individuals who reported adequate access to physicians. Using a population-based survey of New Jersey residents, a difference-in-differences model estimated elderly blacks (OR = 3.20; p = .05) and Hispanics (OR = 4.29; p = .05) had higher odds than whites of reporting prescription access problems in the post, but not the pre-Part D period. The presence of prescription insurance did not lead to a significant decrease in access problems. Part D beneficiaries are required to make complicated decisions on cost-sharing and medication choices that require active involvement by physicians and pharmacists. Lack of guidance may critically impact minorities and economically vulnerable patients and cannot be addressed by extending coverage alone.

Medicaid Utilization and Spending among Homeless Adults in New Jersey: Implications for Medicaid-Funded Tenancy Support Services

Policy Points Large numbers of homeless adults gained Medicaid coverage under the Affordable Care Act, increasing policymaker interest in strategies to improve care and reduce avoidable hospital costs for homeless populations. Compared with nonhomeless adult Medicaid beneficiaries, homeless adult beneficiaries have higher levels of health care needs, due in part to mental health issues and substance use disorders. Homeless adults are also more likely to visit the emergency department or require inpatient admissions. Emergency care and inpatient admissions may sometimes be avoided when individuals have high-quality community-based care and healthful living conditions. Offering tenancy support services that help homeless adults achieve stable housing may therefore be a cost-effective strategy for improving the health of this vulnerable population while reducing spending on avoidable health care interventions. Medicaid beneficiaries with disabling health conditions and more extensive histories of homelessness experience the most potentially avoidable health care interventions and spending, with the greatest opportunity to offset the cost of offering tenancy support benefits.

CONTEXT

Following Medicaid expansion under the Affordable Care Act, the number of homeless adults enrolled in Medicaid has increased. This has spurred interest in developing Medicaid-funded tenancy support services (TSS) for homeless populations as a way to reduce Medicaid spending on health care for these individuals. An emerging body of evidence suggests that such TSS can reduce avoidable health care spending.

METHODS

Drawing on linked Homeless Management Information System and Medicaid claims and encounter data, this study describes the characteristics of homeless adults who could be eligible for Medicaid TSS in New Jersey and compares their Medicaid utilization and spending patterns to matched nonhomeless beneficiaries.

FINDINGS

More than 8,400 adults in New Jersey were estimated to be eligible for Medicaid TSS benefits in 2016, including approximately 4,000 living in permanent supportive housing, 800 formally designated as chronically homeless according to federal guidelines, 1,300 who were likely eligible for the chronically homeless designation, and over 2,000 who were at risk of becoming chronically homeless. Homeless adults in our study were disproportionately between the ages of 30 and 64 years, male, and non-Hispanic blacks. The homeless adults we studied also tended to have very high burdens of mental health and substance use disorders, including opioid-related conditions. Medicaid spending for a homeless beneficiary who was potentially eligible for TSS was 10% ($1,362) to 27% ($5,727) more than spending for a nonhomeless Medicaid beneficiary matched on demographic and clinical characteristics. Hospital inpatient and emergency department utilization accounted for at least three-fourths of "excess" Medicaid spending among the homeless groups.

CONCLUSIONS

A large group of high-need Medicaid beneficiaries could benefit from TSS, and Medicaid funding for TSS could reduce avoidable Medicaid utilization and spending.

Medicaid DSRIP in New Jersey: Trade-offs between Broad Hospital Participation and Safety Net Viability

The Delivery System Reform Incentive Payment (DSRIP) program, an increasingly utilized payment strategy to foster population health management by hospitals and outpatient providers, may sometimes generate financial and operational hardships for safety net hospitals (SNHs). The authors utilized a hospital survey and stakeholder interviews to examine impacts of the New Jersey DSRIP program, particularly focusing on its participatory structure that extended eligibility to all hospitals, and specific effects on SNHs. They found that the New Jersey DSRIP fulfilled its primary objective of conditioning receipt of Medicaid supplementary payments on quality and reporting of care by hospitals. It also provided an impetus to ongoing hospital-directed initiatives and introduced new areas of focus, including behavioral health and obesity. However, stakeholders reported that program implementation was not sensitive to specific constraints, priorities, and resource needs of SNHs. Some of the policies relating to outpatient partnerships, reporting of quality metrics, and monitoring low-income populations were perceived to have placed disproportionate burdens on SNHs. Despite appearing to meet its primary goals, the New Jersey DSRIP experience reveals a critical need to be responsive to problems faced by SNHs so as to limit their short-term transition costs and maintain financial viability for serving their patient populations.

Acquisition and Analysis of Repeating Patterns in Time-oriented Clinical Data

Objectives: (1) Creation of an expressive language for specification of temporal patterns in clinical domains, (2) Development of a graphical knowledge-acquisition tool allowing expert physicians to define meaningful domain-specific patterns, (3) Implementation of an interpreter capable of detecting such patterns in clinical databases, and (4) Evaluation of the tools in the domains of diabetes and oncology.

Methods: We describe a constraint-based language, named CAPSUL, for specification of temporal patterns. We implemented a knowledge-acquisition tool and a temporal-pattern interpreter within Résumé, a larger temporal-abstraction architecture. We evaluated the knowledge-acquisition process with the help of domain experts. In collaboration with the Rush Presbyterian/St. Luke’s Medical Center, we analyzed data of bone-marrow transplantation patients. The expert compared the detected patterns to a manual inspection of the data, with the help of an experimental information-visualization tool we are developing in a related project.

Results: The CAPSUL language was expressive enough during the knowledge-acquisition process to capture almost all of the patterns that the experts found useful. The patterns detected in the data by the pattern interpreter were all verified as correct. Completeness (whether all correct patterns were found) was difficult to assess, due to the size of the database.

Conclusions: The CAPSUL language enables medical experts to express temporal patterns involving multiple levels of abstraction of clinical data. The ability to reuse both domain-patterns and abstract constraints seems highly useful. The Résumé interpreter, augmented by the CAPSUL semantics, finds the complex patterns within a clinical time-oriented database in a sound fashion.

Informing the Design and Evaluation of Superuser Care Management Initiatives: Accounting for Regression-to-the-Mean

BACKGROUND

Health care spending is concentrated among a small number of high-cost patients, and the popularity of initiatives to improve care and reduce cost among such "superusers" (SUs) is growing. However, SU costs decline naturally over time, even without intervention, a statistical phenomenon known as regression-to-the-mean (RTM).

OBJECTIVES

We assess the magnitude of RTM in hospital costs for cohorts of hospital SUs identified on the basis of high inpatient (IP) or emergency department (ED) utilization. We further examine how cost and RTM are associated with patient characteristics including behavioral health (BH) problems, multiple chronic conditions, and indicators of vulnerability.

STUDY DESIGN

Using longitudinally linked all-payer hospital billing data, we selected patient cohorts with ≥2 IP stays (IP SUs) or ≥6 ED visits (ED SUs) during a 6-month baseline period, and additional subgroups defined by combinations of IP and ED superuse.

POPULATION STUDIED

A total of 289,060 NJ hospital IP and treat-and-release ED patients over 2009-2011.

RESULTS

Hospital costs among IP and ED SUs declined 70% and 38%, respectively, over 8 quarters following the baseline period. The decrease occurs more quickly for IP SUs compared with ED SUs. Presence of BH problems was positively associated with costs among patients overall, but the relationship varied by SU cohort.

CONCLUSIONS

Understanding patterns of RTM among SU populations is important for designing intervention strategies, as there is greater potential for savings among patients with more persistent costs (less RTM). Further, as many SU initiatives lack resources for rigorous evaluation, quantifying the extent of RTM is vital for interpreting program outcomes.

Much ado about nothing? The financial impact of physician-owned specialty hospitals

The U.S. hospital industry has recently witnessed a number of policy changes aimed at aligning hospital payments to costs and these can be traced to significant concerns regarding selection of profitable patients and procedures by physician-owned specialty hospitals. The policy responses to specialty hospitals have alternated between payment system reforms and outright moratoriums on hospital operations including one in the recently enacted Affordable Care Act. A key issue is whether physician-owned specialty hospitals pose financial strain on the larger group of general hospitals through cream-skimming of profitable patients, yet there is no study that conducts a systematic analysis relating such selection behavior by physician-owners to financial impacts within hospital markets. The current paper takes into account heterogeneity in specialty hospital behavior and finds some evidence of their adverse impact on profit margins of competitor hospitals, especially for-profit hospitals. There is also some evidence of hospital consolidation in response to competitive pressures by specialty hospitals. Overall, these findings underline the importance of the payment reforms aimed at correcting distortions in the reimbursement system that generate incentives for risk-selection among providers groups. The identification techniques will also inform empirical analysis on future data testing the efficacy of these payment reforms.

Effect of RF power on the structural, optical and gas sensing properties of RF-sputtered Al doped ZnO thin films

The effect of Radio Frequency (RF) power on the properties of magnetron sputtered Al doped ZnO thin films and the related sensor properties are investigated.

Combined toxicity of two crystalline phases (anatase and rutile) of Titania nanoparticles towards freshwater microalgae: Chlorella sp

In view of the increasing usage of anatase and rutile crystalline phases of titania NPs in the consumer products, their entry into the aquatic environment may pose a serious risk to the ecosystem. In the present study, the possible toxic impact of anatase and rutile nanoparticles (individually and in binary mixture) was investigated using freshwater microalgae, Chlorella sp. at low exposure concentrations (0.25, 0.5 and 1mg/L) in freshwater medium under UV irradiation. Reduction of cell viability as well as a reduction in chlorophyll content were observed due to the presence of NPs. An antagonistic effect was noted at certain concentrations of binary mixture such as (0.25, 0.25), (0.25, 0.5), and (0.5, 0.5) mg/L, and an additive effect for the other combinations, (0.25, 1), (0.5, 0.25), (0.5, 1), (1, 0.25), (1, 0.5), and (1, 1) mg/L. The hydrodynamic size analyses in the test medium revealed that rutile NPs were more stable in lake water than the anatase and binary mixtures [at 6h, the sizes of anatase (1mg/L), rutile NPs (1mg/L), and binary mixture (1, 1mg/L) were 948.83±35.01nm, 555.74±19.93nm, and 1620.24±237.87nm, respectively]. The generation of oxidative stress was found to be strongly dependent on the crystallinity of the nanoparticles. The transmission electron microscopic images revealed damages in the nucleus and cell membrane of algal cells due to the interaction of anatase NPs, whereas rutile NPs were found to cause chloroplast and internal organelle damages. Mis-shaped chloroplasts, lack of nucleus, and starch-pyrenoid complex were noted in binary-treated cells. The findings from the current study may facilitate the environmental risk assessment of titania NPs in an aquatic ecosystem.

Impact of Medicare Part D on coverage, access, and disparities among new jersey seniors

The authors used a population-based survey of New Jersey residents to assess outcomes associated with implementation of the Medicare Part D program. Between 2001 and 2009, there was a 24% increase in prescription drug coverage among elderly individuals, but also an increase in cost-related access problems. Compared with the pre-Part D period, seniors reporting access problems post-Part D were less likely to be uninsured and more likely to be publicly insured. Cost-related access disparities among elderly Blacks and Hispanics relative to elderly Whites persisted from 2001 to 2009, and were partly driven by ongoing disparities related to low income. Such cost-based access problems 3 years into implementation implies that they are not transitory and may reflect inadequate subsidy levels alongside the importance of physician advice about prescriptions in ensuring low-cost medication options for vulnerable patients. Finally, the findings, may also reflect success in enrolling high-need seniors into Part D.

The New Jersey Medicaid ACO Demonstration Project: seeking opportunities for better care and lower costs among complex low-income patients

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities.

Antipsychotic medication use in nursing homes: a proposed measure of quality

OBJECTIVE

The potential misuse of antipsychotic medications (APMs) is an ongoing quality concern in nursing homes (NHs), especially given recent black box warnings and other evidence regarding the risk of APMs when used in NH populations. One mechanism regulators could use is public reporting of APM use by NHs; however, there is currently no agreed-upon measure of guideline-inconsistent APM use. In this paper, we describe a proposed measure of quality of APM use that is based on Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, Food and Drug Administration (FDA) indications for APMs, and severity of behavioral symptoms.

METHODS

The proposed measure identifies NH residents who receive an APM but do not have an approved indication for APM use. We demonstrate the feasibility of this measure using data from Medicaid-eligible long-stay residents aged 65 years and older in seven states. Using multivariable logistic regressions, we compare it to the current CMS Nursing Home Compare quality measure.

RESULTS

We find that nearly 52% of residents receiving an APM lack indications approved by CMS/FDA guidelines compared with 85% for the current CMS quality measure. APM guideline-inconsistent use rates vary significantly across resident and facility characteristics, and states. Only our measure correlates with another quality indicator in that facilities with higher deficiencies have significantly higher odds of APM use. Predictors of inappropriate use are found to be consistent with other measures of NH quality, supporting the validity of our proposed measure.

CONCLUSION

The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available.

Health Care and Women's Empowerment: The role of Self Help Groups

Over the last couple of decades the concept of Self Help Groups (SHGs) and its potential as an effective tool to alleviate poverty and empower women has garnered considerable interest worldwide. Considering the importance given by policy makers across various nations to the group approach while conceptualizing, formulating and implementing any scheme or programme for the welfare of marginalized and underprivileged sections of the society (especially women), we identified the need to critically examine and explore the role of SHGs in the empowerment of women with a special emphasis on health status. To date, the functioning of SHGs has essentially been viewed only from an economic perspective. The existing approach puts encourages the economic development of women, with SHGs a mechanism to achieving this. However, how these economic benefits are being translated into the change in women’s status, particularly their health status, remains unexplored and ultimately unaddressed. This working research paper attempts to review the scope and limitations of SHGs in improving women’s health and empowerment based upon empirical work undertaken in the Jharkhand state of India. Our paper also explores the extent to which SHGs can be involved in attaining better health status for women, and thereby point the way for further research.   

Strain relaxation and vacancy creation in thin platinum films

Synchrotron based combined in situ x-ray diffractometry and reflectometry is used to investigate the role of vacancies for the relaxation of residual stress in thin metallic Pt films. From the experimentally determined relative changes of the lattice parameter a and of the film thickness L the modification of vacancy concentration and residual strain was derived as a function of annealing time at 130 °C. The results indicate that relaxation of strain resulting from compressive stress is accompanied by the creation of vacancies at the free film surface. This proves experimentally the postulated dominant role of vacancies for stress relaxation in thin metal films close to room temperature.

Bipolar medication use and adherence to antiretroviral therapy among patients with HIV-AIDS and bipolar disorder

OBJECTIVE

The study examined relationships between adherence to bipolar medication and to antiretroviral therapy, measured by medication fills, among patients with diagnoses of bipolar disorder and HIV infection.

METHODS

A retrospective study was conducted of Medicaid claims data (2001-2004) from eight states, focusing on antiretroviral adherence. The unit of analysis was person-month (N=53,971). The average observation period for the 1,687 patients was 32 months. Analyses controlled for several patient characteristics.

RESULTS

Patients possessed antiretroviral drugs in 72% of the person-months. When a bipolar medication prescription was filled in the prior month, the rate of antiretroviral possession in the subsequent month was 78%, compared with 65% when bipolar medication was not filled in the prior month (p<.001). Odds of antiretroviral possession were 66% higher in months when patients had a prior-month supply of bipolar medication.

CONCLUSIONS

Bipolar medication adherence may improve antiretroviral adherence among patients with bipolar disorder and HIV infection.

Circadian modulation of sodium-potassium ATPase and sodium - proton exchanger in human erythrocytes: in vitro effect of melatonin

Melatonin (N-acetyl-5-methoxytrptamine) is a pineal secretory product which is involved in the regulation of circadian rhythm and participates in many physiological functions. It also acts as a potent antioxidant and a powerful free radical scavenger. The membrane-associated Na+/K+-ATPase and Na+/H+ exchanger in erythrocytes play an important role in maintaining cytosolic pH, ionic homeostasis, cell osmolarity and in the regulation of transmembrane ion movement. The present work was undertaken to determine the role of melatonin in modulating the activity of Na+/K+-ATPase and Na+/H+ exchanger in human erythrocytes. Our observation shows circadian modulation of Na+/K+-ATPase and Na+/H+ exchanger which may have important therapeutic implications. Exogenous melatonin modulated the activities of Na+/K+-ATPase and Na+/H+ exchanger in human red blood cells, this effect may in part be explained due to the antioxidative effect of melatonin and also due to modulation of membrane fluidity. Further work is needed to understand the mechanism of action.

Comparison of Automated Intermittent Low Volume Bolus with Continuous Infusion for Labour Epidural Analgesia

Delivery of local anaesthetics via automated intermittent bolus has been shown to improve epidural analgesia compared to delivery via continuous epidural infusion. However, the optimal bolus volume has not been investigated. This randomised, double-blind study compared the analgesic efficacy of automated intermittent bolus (volume 2.5 ml every 15 minutes) with that of a continuous epidural infusion (10 ml/hour) for the maintenance of labour epidural analgesia, to determine whether the advantages previously demonstrated for automated intermittent bolus over continuous epidural infusion are retained at this low bolus volume. With the approval of the Hospital Ethics Committee, we recruited 50 parturients who received combined spinal epidural analgesia with intrathecal ropivacaine 2 mg and fentanyl 15 μg. For epidural maintenance, participants were randomised to either the automated intermittent bolus group (2.5 ml automated intermittent epidural boluses of ropivacaine 0.1% plus fentanyl 2 μg/ml delivered over a two-minute period every 15 minutes) or the continuous epidural infusion group (continuous epidural infusion of ropivacaine 0.1% plus fentanyl 2 μg/ml at 10 ml/hour). The primary study outcome was the incidence of pain during labour that required management with supplemental epidural analgesia. There were no significant differences between the two regimens in terms of breakthrough pain (automated intermittent bolus 36% [9/25] vs continuous epidural infusion 32% [8/25], P=0.77). At the doses used in this study, maintenance of labour analgesia using automated intermittent bolus at a bolus volume of 2.5 ml every 15 minutes does not decrease the incidence of breakthrough pain or improve analgesic efficacy compared to continuous epidural infusion.

Removal of Pb(II) ions from aqueous solution by adsorption using bael leaves (Aegle marmelos)

Biosorption of Pb(II) on bael leaves (Aegle marmelos) was investigated for the removal of Pb(II) from aqueous solution using different doses of adsorbent, initial pH, and contact time. The maximum Pb loading capacity of the bael leaves was 104 mg g(-1) at 50 mg L(-1) initial Pb(II) concentration at pH 5.1. SEM and FT-IR studies indicated that the adsorption of Pb(II) occurs inside the wall of the hollow tubes present in the bael leaves and carboxylic acid, thioester and sulphonamide groups are involved in the process. The sorption process was best described by pseudo second order kinetics. Among Freundlich and Langmuir isotherms, the latter had a better fit with the experimental data. The activation energy E(a) confirmed that the nature of adsorption was physisorption. Bael leaves can selectively remove Pb(II) in the presence of other metal ions. This was demonstrated by removing Pb from the effluent of exhausted batteries.

Delta FosB overexpression in the nucleus accumbens enhances sexual reward in female Syrian hamsters

Repeated activation of the mesolimbic dopamine system results in persistent behavioral alterations accompanied by a pattern of neural plasticity in the nucleus accumbens (NAc). As the accumulation of the transcription factor Delta FosB may be an important component of this plasticity, the question addressed in our research is whether Delta FosB is regulated by sexual experience in females. We have shown that female Syrian hamsters, given sexual experience, exhibit several behavioral alterations including increased sexual efficiency with naïve male hamsters, sexual reward and enhanced responsiveness to psychomotor stimulants (e.g. amphetamine). We recently demonstrated that sexual experience increased the levels of Delta FosB in the NAc of female Syrian hamsters. The focus of this study was to explore the functional consequences of this induction by determining if the constitutive overexpression of Delta FosB by adeno-associated virus (AAV) vectors in the NAc could mimic the behavioral effects of sexual experience. Animals with AAV-mediated overexpression of Delta FosB in the NAc showed evidence of sexual reward in a conditioned place preference paradigm under conditions in which control animals receiving an injection of AAV-green fluorescent protein (GFP) into the NAc did not. Sexual behavior tests further showed that males paired with the AAV-Delta FosB females had increased copulatory efficiency as measured by the proportion of mounts that included intromission compared to males mated with the AAV-GFP females. These results support a role for Delta FosB in mediating natural motivated behaviors, in this case female sexual behavior, and provide new insight into the possible endogenous actions of Delta FosB.

Numerical simulation of unsteady generalized Newtonian blood flow through differently shaped distensible arterial stenoses

An updated numerical simulation of unsteady generalized Newtonian blood flow through differently shaped distensible arterial stenoses is developed. A shear-thinning fluid modelling the deformation dependent viscosity of blood is considered for the characterization of generalized Newtonian behaviour of blood. The arterial model is treated as two-dimensional and axisymmetric with an outline of the stenosis obtained from a three-dimensional casting of a mildly stenosed artery. The full Navier-Stokes equations governing blood flow are written in the dimensionless form and the solution is accomplished by finite time-step advancement through their finite difference staggered grid representations. The marker and cell (MAC) method comprising the use of a set of marker particles moving with the fluid is used for the purpose. Results are obtained for three differently shaped stenoses - irregular, smooth and cosine curve representations. The present results do agree well with those of existing investigations in the steady state, but contrary to their conclusions the present findings demonstrate that the excess pressure drop across the cosine and the smooth stenoses is caused by neither their smoothness nor their higher degree of symmetry relative to the irregular stenosis, but is rather an effect of area cover with respect to the irregular stenosis. This effect clearly prevails throughout the entire physiological range of Reynolds numbers. Further the in-depth study in flow patterns reveals the development of flow separation zones in the diverging part of the stenosis towards the arterial wall, and they are influenced by non-Newtonian blood rheology, distensibility of the wall and flow unsteadiness in order to validate the applicability of the present model.

Removal of copper from aqueous solution using newspaper pulp as an adsorbent

Newspaper pulp was found to be a potential adsorbent for removal of copper from aqueous medium. Detail adsorption study of Cu on newspaper pulp was investigated. Batch adsorption study was carried out as a function of contact time, adsorbent dose, temperature (303-323 K). The experimental data was analyzed using Freundlich, Langmuir, Dubinin-Radushkevich (D-R) and Redlich-Peterson (R-P) isotherm models. It was found that Freundlich, Langmuir and R-P models fitted well. pH variation study revealed that the adsorption increased with increase in pH of the solution. Maximum loading capacity was found to be 30 mg g(-1) at 20 mg L(-1) of initial Cu concentration. Adsorption data were analyzed using two kinetic models, Lagergren first order and pseudo second order. It was observed that pseudo second order represented the best correlation. Langmuir isotherm was used to obtain the thermodynamic parameters such as free energy (DeltaG degrees ), enthalpy (DeltaH degrees ) and entropy (DeltaS degrees ) of adsorption. The negative value of free energy and positive value of enthalpy change indicate that the adsorption of Cu on newspaper pulp is a spontaneous process and endothermic. The results of activation energy also confirmed that the adsorption of Cu on newspaper pulp is physical in nature. Present investigation emphasized that newspaper pulp may be utilized as a low cost adsorbent for copper removal.

Relevance of glycosylation of human zona pellucida glycoproteins for their binding to capacitated human spermatozoa and subsequent induction of acrosomal exocytosis

To delineate the functional aspects of zona pellucida (ZP) glycoproteins during fertilization in human, in the present study, fluorochrome-conjugated Escherichia coli (E. coli)- and baculovirus-expressed recombinant human ZP glycoprotein-2 (ZP2), -3 (ZP3), and -4 (ZP4) were employed. In an immunofluorescence assay, capacitated human sperm exhibited binding of the baculovirus-expressed recombinant ZP3 as well as ZP4 to either acrosomal cap or equatorial region whereas acrosome-reacted sperm failed to show any binding to the acrosomal cap. Using double labeling experiments, simultaneous binding of ZP3 and ZP4 to the acrosomal cap was observed suggesting the possibility of different binding sites of these proteins on the sperm surface. No binding of ZP2 was observed to the capacitated sperm. However, acrosome-reacted sperm (20.00 +/- 1.93%) showed binding of ZP2 that was restricted to only equatorial region. Interestingly, E. coli-expressed recombinant human zona proteins also showed very similar binding profiles. Competitive inhibition studies with unlabeled recombinant human zona proteins revealed the specificity of the above binding characteristics. Binding characteristics have been further validated by an indirect immunofluorescence assay using native human heat solubilized isolated zona pellucida. Employing baculovirus-expressed recombinant ZP3 and ZP4 with reduced N-linked glycosylation and respective E. coli-expressed recombinant proteins, it was observed that glycosylation is required for induction of acrosomal exocytosis but its absence may not compromise on their binding ability. These studies have revealed the binding profile of individual human zona protein to spermatozoa and further strengthened the importance of glycosylation of zona proteins for acrosomal exocytosis in spermatozoa.

Effect of UV and visible light on photocatalytic reduction of lead and cadmium over titania based binary oxide materials

Uniform sized silica and zirconia mixed titania samples were prepared in presence of a surfactant (CETAB) using controlled hydrolysis of corresponding metal alkoxides. Photocatalytic activity towards reduction of lead and cadmium metal in aqueous solution was evaluated both in UV and visible light in a 100 ml capacity reactor. In particular mixing of 10 wt% silica with titania not only increases the surface area of the material but also increases the photocatalytic activity in UV light. Whereas mixing of zirconia with titania proved to be beneficial for visible light reaction. However, addition of hole scavenger increases the activity many folds and complete removal of Pb(2+) and Cd(2+) was possible in 60 min of reaction using synthesized catalysts. Among all the organic hole scavengers used, sodium formate is found to be the most active one. Interestingly quite high metal removal (89%) is also observed in presence of visible light within 60 min of reaction. Thus the above study indicates that the presence of certain oxides in low quantity (10 wt%) with titania can facilitates the photocatalytic process selectively in UV as well as visible light.

Multiwavelength ultralow-threshold lasing in quantum dot photonic crystal microcavities

We demonstrate multiwavelength lasing of resonant modes in linear (L3) microcavities in a triangular-lattice 2D photonic crystal (PC) slab. The broad spontaneous emission spectrum from coupled quantum dots, modified by the PC microcavity, is studied as a function of the intensity of incident optical excitation. We observe lasing with an ultralow-threshold power of approximately 600 nW and an output efficiency of approximately 3% at threshold. Two other resonant modes exhibit weaker turnon characteristics and thresholds of approximately 2.5 and 200 microW, respectively.