Comparison of age-related declines in behavioral auditory responses versus electrophysiological measures of amplitude modulation.

Amplitude and frequency modulations are important for speech intelligibility, especially in noise. Neurophysiological responses assessed by envelope following responses (EFRs) are smaller at faster amplitude modulation frequencies (AMF) in older subjects compared to younger subjects. A typical assumption is that a decline in EFRs necessarily results in corresponding perceptual deficits. To test this in an animal model, we investigated the behavioral AMF discrimination of young and aged Fischer-344 rats and compared those abilities to their EFRs. A modified version of prepulse inhibition of the acoustic startle reflex was used to measure behavior. When AMF differences and modulation depths were large, young and aged animals' behavioral performances were comparable. Aged animals' discrimination abilities declined as the difference between background and prepulse AMF decreased and as modulation depth decreased. These declines were larger than in younger animals, even compared to young rats with similar peripheral activation (ABR wave I amplitudes), whose EFR amplitudes were smaller than the aged animals. The results revealed larger age-related deficits in behavioral perception compared to EFRs, suggesting additional factors that affect perception in aging.

Care coordination agreements: barriers, facilitators, and lessons learned.

BACKGROUND: With growing pressure to improve the quality and coordination of care, physicians feel a need to streamline their relationships with other practitioners around shared care for patients. Some physicians have developed written agreements that articulate the respective responsibilities of 2 or more parties for coordination of patient care, ie, care coordination agreements (CCAs). OBJECTIVES: To describe how CCAs are formed and explore facilitators and barriers to adoption of effective CCAs, the extent to which CCAs may be replicable in different market contexts, and the implications for policies and programs that aim to improve the coordination of care. STUDY DESIGN: Qualitative study of primary care physicians participating in CCAs and representatives of their specialist, hospital, or community-based partners. METHODS: Semi-structured interviews with participating providers and national thought leaders in care coordination were reviewed to develop key themes. RESULTS: Agreements that address referral and access processes were considered useful by all practices that had implemented them. Practices that implemented agreements including guidance on shared management of specific clinical conditions (comanagement) also found them useful. CCAs were most successful in settings where both parties to the agreement already had stable communication pathways (such as an electronic health record [EHR], designated staff) and strong working relationships. CONCLUSIONS: Policy changes (such as shifts in reimbursement to favor collaborative care or clarification of laws governing such collaborations) can help to support the development and implementation of CCAs, and can address factors that currently make some markets less supportive of coordination.

Hospitals' geographic expansion in quest of well-insured patients: will the outcome be better care, more cost, or both?

The emphasis that hospitals place on cutting-edge technology and niche specialty services to attract physicians and patients has set the stage for health care's most recent competitive trend: an increased level of targeted, geographic service expansion to "capture" well-insured patients. We conducted interviews in twelve US communities in 2010 and found that many hospital systems--some with facilities in geographically undesirable areas--have expanded to compete for better-insured patients by building or buying facilities and physician practices in nearby, more affluent communities. Along with extending services to new markets, these hospital outposts often serve to pull well-insured patients to flagship facilities. The acceleration and expansion of such geographically competitive strategies by hospitals has implications for cost and access. Although payers and competitors contend such strategies will lead to higher costs, hospitals assert the expansions will increase efficiency, increase access, and improve the quality of care provided to patients.