Integrating behavioral health under an ACO global budget: barriers and progress in Oregon.

OBJECTIVES: This study describes challenges that coordinated care organizations (CCOs), a version of accountable care organizations, experienced when attempting to finance integrated care for Medicaid recipients in Oregon and the strategies they developed to address these barriers. STUDY DESIGN: Cross-case comparative study. METHODS: We conducted a cross-case comparative study of 5 diverse CCOs in Oregon. We interviewed key stakeholders: CCO leaders, practice leaders, and primary care and behavioral health clinicians. A multidisciplinary team analyzed data using an immersion-crystallization approach. Financial barriers to integrating care and strategies to address them emerged from this analysis. Findings were member-checked with a CCO integration workgroup to ensure wider applicability. RESULTS: State legislation that initiated CCOs promoted integration expansion. CCOs, however, struggled to create sustainable funding mechanisms to support integration. This was due to regulatory and financial silos that persisted despite CCO global budget formation; concerns about actuarial soundness that limited reasonable, yet creative, uses of federal funds to support integration; and billing difficulties connected to licensing and documentation requirements for behavioral and mental health providers. Despite these barriers, CCOs, with the help of the state, supported expanding integrated care in primary care by using state funds to pilot test integration models and to promote alternative payment methodologies. CONCLUSIONS: Oregon's CCO mandate included a focus on better integrating medical and behavioral healthcare for Medicaid recipients. Despite this intention, challenges exist in the financing of integration, many of which state and federal leaders can address through payment and regulatory reform.

Evaluation of measurement tools for tobacco product displays: is there an app for that?

Tobacco product displays are a pervasive presence in convenience stores, supermarkets, pharmacies, and other retailers nationwide. The influence that tobacco product displays have on purchases and tobacco product initiation, particularly on young people and other vulnerable populations, is well known. An objective measurement tool that is valid, reliable, and feasible to use is needed to assess product displays in the retail setting. This study reports on the relative accuracy of various tools that measure area and/or distance in photos and thus could be applied to product displays. We compare results of repeated trials using five tools. Three tools are smartphone apps that measure objects in photos taken on the device; these are narrowed down from a list of 284 candidate apps. Another tool uses photos taken with any device and calculates relative area via a built-in function in the Microsoft Office Suite. The fifth uses photos taken with the Narrative Clip, a "life-logging" wearable camera. To evaluate validity and reliability, we assess each instrument's measurements and calculate intra-class correlation coefficients. Mean differences between observed measurements (via tape measure) and those from the five tools range from just over one square foot to just over two square feet. Most instruments produce reliable estimates though some are sensitive to the size of the display. Results of this study indicate need for future research to test innovative measurement tools. This paper also solicits further discussion on how best to transform anecdotal knowledge of product displays as targeted and disproportionate marketing tactics into a scientific evidence base for public policy change.

Partnering to create a more livable city: the Livable St Louis Network.

CONTEXT: Physical inactivity is a major public health problem. While individual (eg, attitudes, values, beliefs) and social (eg, social support) factors play a role, access to an activity-safe local environment can have a significant influence. Environments that include accessible opportunities for physical activity, a component of livability, require cooperation from many sectors including nonprofit, government, educational, and for profit. OBJECTIVE/DESIGN/SETTING: This study used a mixed-methods network mapping approach to evaluate a multisector network focused on increasing the livability of St Louis, Missouri. PARTICIPANTS: Eighteen network members participated in in-depth interviews about their livability partners. OUTCOME MEASURES/RESULTS: The participants identified 86 unique partners in the region, with a majority representing nonprofit and government organizations and fewer from the education and for-profit sectors. Participants trusted 88% of their partners and felt that 83% of partners shared their mission and vision. Trust and shared mission and vision varied across organization types. Specifically, 89% of nonprofit partners were thought to share a mission/vision and 87% were trusted. Participants felt that 87% of government partners shared their mission/vision and 91% were trusted. Participants shared mission/vision with 75% and trusted 75% of educational partners. Finally, 44% of for-profit partners were thought to share mission/vision and 100% were trusted. For-profit partners also had more positive influence than others, while government partners had the highest average negative influence. Finally, while most relationships were mutual, relationships with for-profit partners were mostly one-directional, with for-profit partners sending resources to other network members. CONCLUSION: Livability efforts in St Louis might benefit from recruiting additional for-profit partners that provide the network with new perspectives and needed resources, and from cultivating positive partnerships with government organizations that can assist with local policy development and enforcement.

Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department.

BACKGROUND: Although the overuse of antibiotics and underuse of bronchodilators for treatment of acute bronchitis is well known, few studies have analyzed these trends in the emergency department (ED). STUDY OBJECTIVES: To characterize the antibiotic and bronchodilator prescribing practices of physicians at two academic EDs in the diagnosis of acute bronchitis, and to identify factors that may or may not be associated with these practices. METHODS: A computer database was searched retrospectively for all patients with an ED discharge diagnosis of acute bronchitis, and analyzed, looking at the frequency of antibiotic prescriptions, the class of antibiotic prescribed, and several other related factors including age, gender, chief complaint, duration of cough, and comorbid conditions. RESULTS: During the study period, there were 836 cases of acute bronchitis in adults. Of these, 622 (74.0%) were prescribed antibiotics. Of those prescribed antibiotics, 480 (77.2%) were prescribed broad-spectrum antibiotics. Using multivariate analysis (odds ratio, 95% confidence interval), antibiotics were prescribed significantly more often in patients aged 50 years or older (1.7, 1.2-2.5) and in smokers (1.5, 1.0-2.2). Of patients without asthma, 346 (49.9%) were discharged without a bronchodilator, and 631 (91.1%) were discharged without a spacer device. CONCLUSION: Antibiotics are over-prescribed in the ED for acute bronchitis, with broad-spectrum antibiotics making up the majority of the antibiotics prescribed. Age ≥50 years and smoking are associated with higher antibiotic prescribing rates.