Evaluation of a Housing First programme for people from the public mental health sector with severe and persistent mental illnesses and precarious housing: Housing, health and service use outcomes.

AIMS AND CONTEXT: This paper reports the evaluation of the Doorway program (2015-18) in Melbourne, Australia. Doorway extends the original Housing First (HF) model in providing housing support to people with precarious housing at-risk of homelessness with Serious and Persistent Mental Illnesses (SPMIs) receiving care within Victoria's public mental health system. Doorway participants source and choose properties through the open rental market, and receive rental subsidies, assistance, advocacy and brokerage support through their Housing and Recovery Worker (HRW). The aim of this study is to estimate Doorway's impact on participants' housing, quality of life and mental health service use. METHODOLOGY: The study employed a a quasi-experimental study design with a comparison group, adjusted for ten potential confounders. The primary outcome measure was days of secure housing per participant. Secure housing status, health service usage and quality of life (HoNOS) data were extracted from participants' electronic hospital and Doorway records in deidentified, non-reidentifiable form. Analysis for continuous outcome variables was based on multivariate GLM modelling. RESULTS: Doorway housed 89 (57%) of 157 accepted participants. The 157 Doorway participants overall were also housed for significantly more days (119.4 extra days per participant) than control participants, albeit after some delay in locating and moving into housing (mean 14 weeks). There was a significant, positive Doorway effect on health outcomes (all and one dimension of the HoNOS). Doorway participants had significantly reduced length of stay during acute and community hospital admissions (7.4 fewer days per participant) compared with the control group. CONCLUSION: The Doorway model represents a new and substantial opportunity to house, enhance health outcomes and reduce mental health service use for people with SPMIs from the public mental health sector and at-risk of homelessness.

Electronic Pill Bottles or Bidirectional Text Messaging to Improve Hypertension Medication Adherence (Way 2 Text): a Randomized Clinical Trial.

BACKGROUND: Poor medication adherence contributes to inadequate control of hypertension. However, the value of adherence monitoring is unknown. OBJECTIVE: To evaluate the impact of monitoring adherence with electronic pill bottles or bidirectional text messaging on improving hypertension control. DESIGN: Three-arm pragmatic randomized controlled trial. PATIENTS: One hundred forty-nine primary care patients aged 18-75 with hypertension and text messaging capabilities who were seen at least twice in the prior 12 months with at least two out-of-range blood pressure (BP) measurements, including the most recent visit. INTERVENTIONS: Patients were randomized in a 1:2:2 ratio to receive (1) usual care, (2) electronic pill bottles for medication adherence monitoring (pill bottle), and (3) bidirectional text messaging for medication adherence monitoring (bidirectional text). MAIN MEASURES: Change in systolic BP during the final 4-month visit compared with baseline. KEY RESULTS: At the 4-month follow-up visit, mean (SD) change values in systolic blood pressure were - 4.7 (23.4) mmHg in usual care, - 4.3 (21.5) mmHg in the pill bottle arm, and - 4.6 (19.8) mmHg in the text arm. There was no significant change in systolic blood pressure between control and the pill bottle arm (p = 0.94) or the text messaging arm (p = 1.00), and the two intervention arms did not differ from each other (p = 0.93). CONCLUSIONS: Despite good measured adherence, neither feedback with electronic pill bottles nor bidirectional text messaging about medication adherence improved blood pressure control. Adherence to prescribed medications was not improved enough to affect BP control or it was not the primary driver of poor control. TRIAL REGISTRATION: clinicaltrials.gov (NCT02778542).

Impact of an interprofessional transition of care service on 30-day hospital reutilizations.

The objective of this study was to evaluate the impact of an interprofessional Transitions of Care (TOC) service on 30-day hospital reutilization inclusive of hospital readmissions and ED visits. This was a retrospective cohort study including patients discharged from an academic medical center between September 2013 and October 2014. Patients scheduled for a hospital follow-up visit in the post-acute care clinic (PACC) were included in the intervention group and patients without a post-discharge interprofessional TOC service were included in the comparison group. The intervention included a hospital follow-up visit with an interprofessional healthcare team. The primary composite outcome was hospital reutilization, defined as a hospital readmission or ED visit within 30 days of the discharge date. Overall, 330 patients were included in each group. In the intention-to-treat analysis, the primary composite outcome was not significantly different between groups (16.97% vs. 19.39%, P = 0.4195) whereas in the per-protocol analysis (all patients who showed to their PACC appointment), the primary outcome was significantly different in favor of the intervention group (9.28% vs. 19.39%, P = 0.0009). When components were analyzed separately, there was a statistically significant difference in favor of intervention group for hospital readmissions, but there was no difference for ED visits. This study demonstrates that an outpatient interprofessional TOC service with patient engagement from a team of nurses, pharmacists, physicians, and social workers may reduce 30-day hospital readmissions but may not impact 30-day ED visits.

Constraining estimates of global soil respiration by quantifying sources of variability.

Quantifying global soil respiration (RSG ) and its response to temperature change are critical for predicting the turnover of terrestrial carbon stocks and their feedbacks to climate change. Currently, estimates of RSG range from 68 to 98 Pg C year-1 , causing considerable uncertainty in the global carbon budget. We argue the source of this variability lies in the upscaling assumptions regarding the model format, data timescales, and precipitation component. To quantify the variability and constrain RSG , we developed RSG models using Random Forest and exponential models, and used different timescales (daily, monthly, and annual) of soil respiration (RS ) and climate data to predict RSG . From the resulting RSG estimates (range = 66.62-100.72 Pg), we calculated variability associated with each assumption. Among model formats, using monthly RS data rather than annual data decreased RSG by 7.43-9.46 Pg; however, RSG calculated from daily RS data was only 1.83 Pg lower than the RSG from monthly data. Using mean annual precipitation and temperature data instead of monthly data caused +4.84 and -4.36 Pg C differences, respectively. If the timescale of RS data is constant, RSG estimated by the first-order exponential (93.2 Pg) was greater than the Random Forest (78.76 Pg) or second-order exponential (76.18 Pg) estimates. These results highlight the importance of variation at subannual timescales for upscaling to RSG. The results indicated RSG is lower than in recent papers and the current benchmark for land models (98 Pg C year-1 ), and thus may change the predicted rates of terrestrial carbon turnover and the carbon to climate feedback as global temperatures rise.

Social Incentives and Gamification to Promote Weight Loss: The LOSE IT Randomized, Controlled Trial.

BACKGROUND: Social networks influence obesity patterns, but interventions to leverage social incentives to promote weight loss have not been well evaluated. OBJECTIVE: To test the effectiveness of gamification interventions designed using insights from behavioral economics to enhance social incentives to promote weight loss. DESIGN: The Leveraging Our Social Experiences and Incentives Trial (LOSE IT) was a 36-week randomized, controlled trial with a 24-week intervention and 12-week follow-up. PARTICIPANTS: One hundred and ninety-six obese adults (body mass index ≥ 30) comprising 98 two-person teams. INTERVENTIONS: All participants received a wireless weight scale, used smartphones to track daily step counts, formed two-person teams with a family member or friend, and selected a weight loss goal. Teams were randomly assigned to control or one of two gamification interventions for 36 weeks that used points and levels to enhance collaborative social incentives. One of the gamification arms also had weight and step data shared regularly with each participant's primary care physician (PCP). MAIN OUTCOME MEASURES: The primary outcome was weight loss at 24 weeks. Secondary outcomes included weight loss at 36 weeks. KEY RESULTS: At 24 weeks, participants lost significant weight from baseline in the control arm (mean: - 3.9 lbs; 95% CI: - 6.1 to - 1.7; P < 0.001), the gamification arm (mean: - 6.6 lbs; 95% CI: - 9.4 to - 3.9; P < 0.001), and the gamification arm with PCP data sharing (mean: - 4.8 lbs; 95% CI: - 7.4 to - 2.3; P < 0.001). At 36 weeks, weight loss from baseline remained significant in the control arm (mean: - 3.5 lbs; 95% CI: - 6.1 to - 0.8; P = 0.01), the gamification arm (mean: - 6.3 lbs; 95% CI: - 9.2 to - 3.3; P < 0.001), and the gamification arm with PCP data sharing (mean: - 5.2 lbs; 95% CI: - 8.5 to - 2.0; P < 0.01). However, in the main adjusted model, there were no significant differences in weight loss between each of the intervention arms and control at either 12, 24, or 36 weeks. CONCLUSIONS: Using digital health devices to track behavior with a partner led to significant weight loss through 36 weeks, but the gamification interventions were not effective at promoting weight loss when compared to control. TRIAL REGISTRATION: clinicaltrials.gov Identifier: 02564445.

Using Active Choice Within the Electronic Health Record to Increase Influenza Vaccination Rates.

BACKGROUND: Despite the benefits of influenza vaccination, each year more than half of adults in the United States do not receive it. OBJECTIVE: To evaluate the association between an active choice intervention in the electronic health record (EHR) and changes in influenza vaccination rates. DESIGN: Observational study. PATIENTS: Adults eligible for influenza vaccination with a clinic visit at one of three internal medicine practices at the University of Pennsylvania Health System between September 2010 and March 2013. INTERVENTION: The EHR confirmed patient eligibility during the clinic visit and, upon accessing the patient chart, prompted the physician and their medical assistant to actively choose to "accept" or "cancel" an order for the influenza vaccine. MAIN MEASURES: Change in influenza vaccination order rates at the intervention practice compared to two control practices for the 2012-2013 flu season, comparing trends during the prior two flu seasons adjusting for time trends and patient and clinic visit characteristics. KEY RESULTS: The sample (n = 45,926 patients) was 62.9% female, 35.9% white, and 54.4% black, with a mean age of 50.2 years. Trends were similar between practices during the 2 years in the pre-intervention period. Vaccination rates increased in both groups in the post-intervention year, but the intervention practice using active choice had a significantly greater increase than the control (adjusted difference-in-difference: 6.6 percentage points; 95% CI, 5.1-8.1; P < 0.001), representing a 37.3% relative increase compared to the pre-intervention period. More than 99.9% (9938/9941) of orders placed during the study period resulted in vaccination. CONCLUSIONS: Active choice through the EHR was associated with a significant increase in influenza vaccination rates.

Board Certification: The Global Perspective.

This article reviews globalization of quality standards in medicine, with emphasis on accreditation and certification. In conjunction with the 100th anniversary of the American Board of Ophthalmology, the author explores globalization movements, standards of quality, expectations of others seeking certification, the American Board of Medical Specialties (ABMS) International, interrelationships with the ABMS, and considerations both pragmatic and philosophical in addressing globalization of standards.

Using default options within the electronic health record to increase the prescribing of generic-equivalent medications: a quasi-experimental study.

BACKGROUND: Low-value services, such as prescribing brand-name medications that have existing generic equivalents, contribute to unnecessary health care spending. OBJECTIVE: To evaluate the association of an intervention by using the electronic health record with provider prescription of generic-equivalent medications. DESIGN: Quasi-experimental study. SETTING: General internal medicine (IM) (n = 2) and family medicine (FM) (n = 2) clinics at the University of Pennsylvania from June 2011 to September 2012. PARTICIPANTS: Attending physicians (IM, n = 38; FM, n = 17) and residents (IM, n = 166; FM, n = 34). INTERVENTION: In January 2012, the default in the electronic health record was changed for IM providers from displaying brand and generic medications to displaying initially only generics, with the ability to opt out. MEASUREMENTS: Monthly prescriptions of brand-name and generic-equivalent ß-blockers, statins, and proton-pump inhibitors. RESULTS: During the preintervention period, FM providers had slightly higher rates of generic medication prescribing (range, 80.8% to 85.5%) than did IM providers (range, 75.4% to 79.6%), but both groups had similar trends. In the postintervention period relative to the preintervention period, IM providers had an increase in generic prescribing compared with FM providers for all 3 medications combined (5.4 percentage points [95% CI, 2.2 to 8.7 percentage points]; P < 0.001), ß-blockers (10.5 percentage points [CI, 5.8 to 15.2 percentage points]; P < 0.001), and statins (4.0 percentage points [CI, 0.4 to 7.6 percentage points]; P = 0.002). Results for proton-pump inhibitors (2.1 percentage points [CI, -3.7 to 8.0 percentage points]; P = 0.47) were not significant. Subset analyses revealed similar findings for attending physicians. Among residents, however, results were imprecise, with wide CIs. LIMITATION: Observational single-center evaluation, comparison groups that represented different specialties, and a small subset of medication classes studied. CONCLUSION: The use of default options was an effective method to increase the odds of prescribing generic medication equivalents for ß-blockers and statins. PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs and Robert Wood Johnson Foundation.

Preliminary development and validation of the Supervisee Attachment Strategies Scale (SASS).

The influence of counselor trainees' adult attachment orientations in the context of supervision has the potential to inform both training and supervision practice. However, the pursuit of such research requires the availability of appropriate assessment tools. The present study describes the development and validation of the Supervisee Attachment Strategies Scale (SASS), a theory-based measure of counseling trainees' attachment orientations toward their clinical supervisors. Participants were recruited online through their training directors at Association of Psychology Postdoctoral and Internship Centers member programs. Data were nationally collected from 352 trainees representing programs in the United States and Canada. Exploratory factor analysis yielded 2 interpretable factors along the adult attachment dimensions of avoidance vs. engagement and rejection concern vs. security. These 2 factors accounted for 55.85% of the interitem variance in the rotated solution of the 22-item SASS scale. SASS subscale scores were negatively correlated with the supervisory working alliance and predicted greater endorsement of role conflict and role ambiguity in the current supervisory relationship. Higher avoidance (but not rejection concern) predicted diminished perceptions of satisfaction with the overall training experience. Findings from this study suggest that trainees who engaged in adaptive attachment strategies may be more likely to address conflict, negotiate additional explorative opportunities in training, and seek out their supervisors in times of uncertainty.

Early anticoagulation in patients with stroke and atrial fibrillation is associated with fewer ischaemic lesions at 1 month: the ATTUNE study.

BACKGROUND: The optimal time to commence anticoagulation in patients with atrial fibrillation (AF) after ischaemic stroke or transient ischaemic attack (TIA) is unclear, with guidelines differing in recommendations. A limitation of previous studies is the focus on clinically overt stroke, rather than radiologically obvious diffusion-weighted imaging ischaemic lesions. We aimed to quantify silent ischaemic lesions and haemorrhages on MRI at 1 month in patients commenced on early (<4 days) vs late (≥4 days) anticoagulation. We hypothesised that there would be fewer ischaemic lesions and more haemorrhages in the early anticoagulant group at 1-month MRI. METHODS: A prospective multicentre, observational cohort study was performed at 11 Australian stroke centres. Clinical and MRI data were collected at baseline and follow-up, with blinded imaging assessment performed by two authors. Timing of commencement of anticoagulation was at the discretion of the treating stroke physician. RESULTS: We recruited 276 patients of whom 208 met the eligibility criteria. The average age was 74.2 years (SD±10.63), and 79 (38%) patients were female. Median National Institute of Health Stroke Scale score was 5 (IQR 1-12). Median baseline ischaemic lesion volume was 5 mL (IQR 2-17). There were a greater number of new ischaemic lesions on follow-up MRI in patients commenced on anticoagulation ≥4 days after index event (17% vs 8%, p=0.04), but no difference in haemorrhage rates (22% vs 32%, p=0.10). Baseline ischaemic lesion volume of ≤5 mL was less likely to have a new haemorrhage at 1 month (p=0.02). There was no difference in haemorrhage rates in patients with an initial ischaemic lesion volume of >5 mL, regardless of anticoagulation timing. CONCLUSION: Commencing anticoagulation <4 days after stroke or TIA is associated with fewer ischaemic lesions at 1 month in AF patients. There is no increased rate of haemorrhage with early anticoagulation. These results suggest that early anticoagulation after mild-to-moderate acute ischaemic stroke associated with AF might be safe, but randomised controlled studies are needed to inform clinical practice.

Relationship between woody plant colonization and Typha L. encroachment in stormwater detention basins.

We studied stormwater detention basins where woody vegetation removal was suspended for 2 years in Virginia, USA to determine if woody vegetation can control Typha populations and how early woody plant succession interacts with Typha, other herbaceous vegetation, and site factors. Distribution and composition of woody vegetation, Typha and non-Typha herbaceous vegetation biomass, and site factors were assessed at 100 plots in four basins ranging in age from 7 to 17 years. A greenhouse study examined the interaction of shade and soil moisture on Typha biomass and persistence. Principal component analysis identified an environmental gradient associated with greater water table depths and decreased elevation that favored Typha but negatively influenced woody vegetation. Elevation was correlated with litter layer distribution, suggesting that initial topography influences subsequent environmental characteristics and thus plant communities. Soil organic matter at 0-10 cm ranged from 5.4 to 12.7%. Woody plants present were native species with the exception of Ailanthus altissima and Pyrus calleryana. In the greenhouse, shade and reduced soil moisture decreased Typha biomass and rhizome length. The shade effect was strongest in flooded plants and the soil moisture effect was strongest for plants in full sun. Typha in dry soil and heavy shade had 95% less total biomass and 83% smaller rhizomes than Typha in flooded soil and full sun, but even moderate soil moisture reductions decreased above- and below-ground biomass by 63 and 56%, respectively. Suspending maintenance allows restoration of woody vegetation dominated by native species and may suppress Typha invasion.

A cross-cultural comparison of a measure of parent perceptions among families of children with autism in Vietnam.

LAY ABSTRACT: Raising an autistic child can affect many aspects of families' lives. Parents are responsible for many decisions, from initiating evaluation to selecting and implementing treatments. How parents conceptualize the course and nature of their child's diagnosis influences these processes and parents' own well-being. Parents' perceptions about their children's autism are also affected by cultural contexts and understanding of autism. The Illness Perception Questionnaire-Revised (IPQ-R) is widely used to study cognitions in chronic health research and has been adapted and validated to measure parents' perceptions and beliefs about their children's ASD (IPQ-R-ASD). However, such studies are mostly conducted in high-income countries (HICs) with western, individualistic cultural values (e.g. United States, Canada). Therefore, it is unclear whether the IPQ-R-ASD is a useful instrument in understanding parents' perceptions of autism in Vietnam, a lower- and middle-income country (LMIC) with collectivistic Asian cultural values. These differences suggest that parents in Vietnam may have cognitive representations of their children's autism that differ from those of parents living in HIC, western countries. The purpose of this study was to examine the usability of the translated Vietnamese IPQ-R-ASD that may, ultimately, help explore Vietnamese parents' autism perceptions. While the study's result indicated the usability of the translated measure in Vietnam, when interpreted with Vietnamese norms, results also highlighted notable differences between Vietnamese and North American parents' perceptions of autism that warrant further research.

Congenital ectopic cilia of the upper eyelid.

The authors report a 19-year-old woman with a cluster of ectopic cilia located in the temporal aspect of her right upper eyelid associated with symptomatic secretion from the cutaneous ostea of the cilia. Histologic examination revealed subcutaneous connective tissue interspersed with pilosebaceous follicles and apocrine glands. No evidence of lacrimal gland ducts or acini was found.

Two generations at risk: child welfare, institutional boundaries, and family violence in grandparent homes.

Participation of extended family members, particularly custodial grandparents, has generally resulted in better outcomes for abused children and relief for an overburdened child welfare system. This research explores the risk of adolescent perpetrated violence in custodial grandparent households with data from the Florida Department of Juvenile Justice. Findings suggest that living arrangements with custodial grandparents have a significant and differential impact on rates of violent offending for chronic and serious offenders by race and gender.

Behavioral interventions to improve population health outreach for hepatitis C screening: randomized clinical trial.

OBJECTIVE: To evaluate whether opt out framing, messaging incorporating behavioral science concepts, or electronic communication increases the uptake of hepatitis C virus (HCV) screening in patients born between 1945 and 1965. DESIGN: Pragmatic randomized controlled trial. SETTING: 43 primary care practices from one academic health system (Philadelphia, PA, USA) between April 2019 and May 2020. PARTICIPANTS: Patients born between 1945 and 1965 with no history of screening and at least two primary care visits in the two years before the enrollment period. INTERVENTIONS: This multilevel trial was divided into two studies. Substudy A included 1656 eligible patients of 17 primary care clinicians who were randomized in a 1:1 ratio to a mailed letter about HCV screening (letter only), or a similar letter with a laboratory order for HCV screening (letter+order). Substudy B included the remaining 19 837 eligible patients followed by 417 clinicians. Active electronic patient portal users were randomized 1:5 to receive a mailed letter about HCV screening (letter), or an electronic patient portal message with similar content (patient portal); inactive patient portal users were mailed a letter. In a factorial design, patients in substudy B were also randomized 1:1 to receive standard content (usual care), or content based on principles of social norming, anticipated regret, reciprocity, and commitment (behavioral content). MAIN OUTCOME MEASURES: Proportion of patients who completed HCV testing within four months. RESULTS: 21 303 patients were included in the intention-to-treat analysis. Among the 1642 patients in substudy A, 19.2% (95% confidence interval 16.5% to 21.9%) completed screening in the letter only arm and 43.1% (39.7% to 46.4%) in the letter+order arm (P<0.001). Among the 19 661 patients in substudy B, 14.6% (13.9% to 15.3%) completed screening with usual care content and 13.6% (13.0% to 14.3%) with behavioral science content (P=0.06). Among active patient portal users, 17.8% (16.0% to 19.5%) completed screening after receiving a letter and 13.8% (13.1% to 14.5%) after receiving a patient portal message (P<0.001). CONCLUSIONS: Opt out framing and effort reduction by including a signed laboratory order with outreach increased screening for HCV. Behavioral science messaging content did not increase uptake, and mailed letters achieved a greater response rate than patient portal messages. TRIAL REGISTRATION: ClinicalTrials.gov NCT03712553.

Phenotyping physician practice patterns and associations with response to a nudge in the electronic health record for influenza vaccination: A quasi-experimental study.

BACKGROUND: Health systems routinely implement changes to the design of electronic health records (EHRs). Physician behavior may vary in response and methods to identify this variation could help to inform future interventions. The objective of this study was to phenotype primary care physician practice patterns and evaluate associations with response to an EHR nudge for influenza vaccination. METHODS AND FINDINGS: During the 2016-2017 influenza season, 3 primary care practices at Penn Medicine implemented an active choice intervention in the EHR that prompted medical assistants to template influenza vaccination orders for physicians to review during the visit. We used latent class analysis to identify physician phenotypes based on 9 demographic, training, and practice pattern variables, which were obtained from the EHR and publicly available sources. A quasi-experimental approach was used to evaluate response to the intervention relative to control practices over time in each of the physician phenotype groups. For each physician latent class, a generalized linear model with logit link was fit to the binary outcome of influenza vaccination at the patient visit level. The sample comprised 45,410 patients with a mean (SD) age of 58.7 (16.3) years, 67.1% were white, and 22.1% were black. The sample comprised 56 physicians with mean (SD) of 24.6 (10.2) years of experience and 53.6% were male. The model segmented physicians into groups that had higher (n = 41) and lower (n = 15) clinical workloads. Physicians in the higher clinical workload group had a mean (SD) of 818.8 (429.1) patient encounters, 11.6 (4.7) patient appointments per day, and 4.0 (1.1) days per week in clinic. Physicians in the lower clinical workload group had a mean (SD) of 343.7 (129.0) patient encounters, 8.0 (2.8) patient appointments per day, and 3.1 (1.2) days per week in clinic. Among the higher clinical workload group, the EHR nudge was associated with a significant increase in influenza vaccination (adjusted difference-in-difference in percentage points, 7.9; 95% CI, 0.4-9.0; P = .01). Among the lower clinical workload group, the EHR nudge was not associated with a significant difference in influenza vaccination rates (adjusted difference-in-difference in percentage points, -1.0; 95% CI, -5.3-5.8; P = .90). CONCLUSIONS: A model-based approach categorized physician practice patterns into higher and lower clinical workload groups. The higher clinical workload group was associated with a significant response to an EHR nudge for influenza vaccination.

Seeking Consensus on the Terminology of Value-Based Transformation Through use of a Delphi Process.

Collaboration among diverse stakeholders involved in the value transformation of health care requires consistent use of terminology. The objective of this study was to reach consensus definitions for the terms value-based care, value-based payment, and population health. A modified Delphi process was conducted from February 2017 to July 2017. An in-person panel meeting was followed by 3 rounds of surveys. Panelists anonymously rated individual components of definitions and full definitions on a 9-point Likert scale. Definitions were modified in an iterative process based on results of each survey round. Participants were a panel of 18 national leaders representing population health, health care delivery, academic medicine, payers, patient advocacy, and health care foundations. Main measures were survey ratings of definition components and definitions. At the conclusion of round 3, consensus was reached on the following definition for value-based payment, with 13 of 18 panelists (72.2%) assigning a high rating (7- 9) and 1 of 18 (5.6%) assigning a low rating (1-3): "Value-based payment aligns reimbursement with achievement of value-based care (health outcomes/cost) in a defined population with providers held accountable for achieving financial goals and health outcomes. Value-based payment encourages optimal care delivery, including coordination across healthcare disciplines and between the health care system and community resources, to improve health outcomes, for both individuals and populations." The iterative process elucidated specific areas of agreement and disagreement for value-based care and population health but did not reach consensus. Policy makers cannot assume uniform interpretation of other concepts underlying health care reform efforts.

The effect of continuing professional education on health care outcomes: lessons for dementia care.

BACKGROUND: This review presents an overview of the published literature on the effectiveness of continuing professional education (CPE), which includes continuing medical education (CME) of different health care professionals in healthcare settings, for improving patient management and patient outcomes. This review summarizes key articles published on the subject, including those relating to dementia care. METHODS: A literature search was carried out using the National Library of Medicine's PubMed database, Cochrane database and Eric databases. RESULTS: Studies on CPE generally provide conflicting evidence on their effectiveness in bringing about a change in professional practices and healthcare outcomes. However interactive, multifaceted interventions, and interventions with repeated inputs appear more effective in bringing about positive changes than traditional non-interactive techniques. There are relatively few studies specifically concerning CPE and dementia care. CONCLUSION: This review shows that CPE in dementia care needs to be targeted carefully. Much can be learnt from examining education approaches in the wider professional and medical education literature.