Launching Financial Incentives for Physician Groups to Improve Equity of Care by Patient Race and Ethnicity.

Policy Points What are the facilitators and barriers of physician group participation in a performance-based financial incentive program aimed at improving equity of care by patient race and ethnicity? Launching financial incentives to improve racial equity has required extensive organizational change management for participating physician groups, including major investments to improve quality management systems. Carefully designing financial incentives to encourage equity improvement while managing unintended consequences, and considering physician groups' populations served, baseline maturity of quality management systems, and efforts to assess and address patients' social risk factors have been central to prepare physician groups for financial incentives to improve equity of care. Given the major investments required of physician groups to prepare for financial incentives that reward equity improvement, alignment of equity of care measure specifications and reporting requirements across payers could facilitate physician group engagement. Evidence about how baseline physician group capabilities, including the maturity of their quality management systems, impact equity improvement may help health plans prioritize and target their investments to advance equity of care by patient race and ethnicity. CONTEXT: Blue Cross Blue Shield of Massachusetts (BCBSMA), a large commercial health insurer, is using financial incentives to advance equity of care by patient race and ethnicity. Understanding experiences of this payer and its contracted physician groups can inform efforts elsewhere. We qualitatively assess physician groups' barriers and facilitators of planning and implementing BCBSMA's financial incentives to improve equity of ambulatory care quality by patient race and ethnicity. METHODS: Key informant interviews (n = 44) of the physician group, BCBSMA, and external stakeholders were conducted, equity initiative meetings were observed, and documents were analyzed to identify barriers and facilitators of designing and preparing for financial incentives to advance racial equity. Physician group experiences of preparing for and responding to financial incentives for equity improvement were assessed. FINDINGS: Analyses revealed 1) the central importance of valid and reliable equity performance measurement and carefully designed equity improvement incentives for physician group buy-in, 2) that prior to implementing financial incentives for equity improvement, physician groups needed to improve their quality management systems and the accuracy and completeness of patient race and ethnicity data, and 3) physician groups' populations served, baseline maturity of quality management systems, and efforts to assess and address patients' social risk factors were central to consider to plan for physician group financial incentives to improve racial equity. CONCLUSIONS: Given the major infrastructure investments and organizational change management resources required of physician groups to participate in a financial incentive program designed to reward equity improvement, alignment of equity measurement and performance requirements across payers would facilitate physician groups' engagement in efforts to improve quality of care for racial and ethnic minority patients.

Steering clear of Akrasia: An integrative review of self-binding Ulysses Contracts in clinical practice.

In many jurisdictions, legal frameworks afford patients the opportunity to make prospective medical decisions or to create directives that contain a special provision forfeiting their own ability to object to those decisions at a future time point, should they lose decision-making capacity. These agreements have been described with widely varying nomenclatures, including Ulysses Contracts, Odysseus Transfers, Psychiatric Advance Directives with Ulysses Clauses, and Powers of Attorney with Special Provisions. As a consequence of this terminological heterogeneity, it is challenging for healthcare providers to understand the terms and uses of these agreements and for ethicists to engage with the nuances of clinical decision-making with such unique provisions surrounding patient autonomy. In theory, prospective self-binding agreements may safeguard patient's "authentic" wishes from future "inauthentic" changes of mind. In practice, it is unclear what may be comprised within these agreements or how-and to what effect-they are used. The primary focus of this integrative review is to curate the existing literature describing Ulysses Contracts (and analogous decisions) used in the clinical arena, in order to empirically synthesize their shared essence and provide insights into the traditional components of these agreements when used in practice, the requirements of their consent processes, and the outcomes of their utilization.

"What are my options?": Physicians as ontological decision architects in surgical informed consent.

The aim of a theoretically ideal process of informed consent is to promote the autonomy of the patient and to limit unethical physician paternalism. However, in practice, the nature of the medical profession requires physicians to act as ontological decision architects-based on the medical knowledge that they acquire through their experience and training, physicians ontologically determine a subset of viable courses of action for their patient. What is observed is not an unethical physician limitation or biasing of the patient towards certain treatment options that violates patient autonomy or consciously undermines informed consent, but rather a more foundational paternalism that is necessarily inherent to the physician-patient relationship. In this article we argue for a recognition of this underlying physician paternalism and posit that this necessary paternalism is not a foil to patient autonomy, but rather a foundational aspect of the duties of the medical professional within the physician-patient relationship.

Mental health symptoms and association with COVID-19 vaccination receipt and intention to vaccinate among adults, United States.

Early studies suggest that adults with mental health conditions are at greater risk for COVID-19 infection, severe complications, and higher mortality, yet face barriers in accessing timely health services. Data from the Census Bureau's Household Pulse Survey, a large, nationally representative survey fielded from March 17-29, 2021 (n = 77,104) were analyzed to examine COVID-19 vaccination and intention among adults with mental health symptoms. Separate multivariable regression models were conducted to examine associations between symptoms of anxiety, depression, and anxiety or depression on vaccine receipt (≥ 1 dose) and intention to be vaccinated. Reasons for not being vaccinated were also assessed. Approximately 35% of adults had symptoms of anxiety or depression. This population was less likely to receive COVID-19 vaccination (adjusted prevalence ratio (aPR) = 0.94, 95%CI: 0.91-0.98) but more likely to intend to get a vaccine (aPR = 1.13, 95%CI: 1.08-1.19) than those without these conditions. Females with mental health symptoms were less likely to receive a COVID-19 vaccination but more likely to intend to get vaccinated, while there were fewer significant associations between mental health symptoms and vaccination coverage and intentions to vaccinate among males. Reasons for not getting vaccinated, including concerns about possible vaccine side effects, efficacy, cost, dislike of vaccines, as well as lack of trust in the government and vaccines, were all greater among those with any symptoms of anxiety or depressive disorders than those without symptoms. Efforts are needed to increase vaccination uptake and confidence among this vulnerable population by increasing vaccine confidence and addressing concerns about the vaccine.

Understanding Health Priorities, Behaviors, and Service Utilization Among Brazilian Immigrant Women: Implications for Designing Community-Based Interventions.

Brazilians represent a growing proportion of immigrants in the USA. Little is known about their health or healthcare utilization after their arrival. This study aimed to gather formative data to understand the needs of Brazilian immigrant women to guide public health interventions. We conducted five focus groups with Brazilian women born in Brazil (n = 47) and 13 key informant interviews with representatives from Brazilian-serving organizations. Participants were recruited from churches and social service organizations in the Greater Boston area. Findings revealed that mental health was the most pressing health priority; many attributed high levels of anxiety and depression to worries about undocumented status, separation from social networks, and strenuous work schedules. Occupational health issues were frequently mentioned, including musculoskeletal complaints, skin rashes, and respiratory problems. Domestic violence was also a concern, and many women feared reporting to police due to undocumented status. Most reported good access to medical care and described the quality of healthcare services as superior to that available in Brazil. However, many reported challenges with interpersonal communication with providers, dissatisfaction with a perceived unwillingness from providers to order medical tests or prescribe treatment, and limited access to mental health services. There was agreement that effective intervention strategies should use social media, radio, and group education in churches.

Believing in black boxes: machine learning for healthcare does not need explainability to be evidence-based.

OBJECTIVE: To examine the role of explainability in machine learning for healthcare (MLHC), and its necessity and significance with respect to effective and ethical MLHC application. STUDY DESIGN AND SETTING: This commentary engages with the growing and dynamic corpus of literature on the use of MLHC and artificial intelligence (AI) in medicine, which provide the context for a focused narrative review of arguments presented in favour of and opposition to explainability in MLHC. RESULTS: We find that concerns regarding explainability are not limited to MLHC, but rather extend to numerous well-validated treatment interventions as well as to human clinical judgment itself. We examine the role of evidence-based medicine in evaluating inexplicable treatments and technologies, and highlight the analogy between the concept of explainability in MLHC and the related concept of mechanistic reasoning in evidence-based medicine. CONCLUSION: Ultimately, we conclude that the value of explainability in MLHC is not intrinsic, but is instead instrumental to achieving greater imperatives such as performance and trust. We caution against the uncompromising pursuit of explainability, and advocate instead for the development of robust empirical methods to successfully evaluate increasingly inexplicable algorithmic systems.

Esthetic Interdisciplinary Treatment: An Effective Approach to Address Complex Short-Face Adult Cases.

Traditional interdisciplinary treatment (IDT) for simultaneous correction of complex facial, smile, and dental problems in a so-called "shortface" adult patient can be extremely challenging. Such treatment typically has been based mainly on dental diagnosis with little or no consideration given to the proper correspondence of teeth position to the patient's jaws so as to enhance overall esthetics. Modern esthetic interdisciplinary treatment (E-IDT), however, is an overall esthetics-driven treatment planning approach based on a global diagnosis rather than primarily a dental diagnosis, while still considering the patient's health and function. This article, which features a clinical report, describes treatment of a woman with a short, square face who originally was contemplating cosmetic surgery for correction of her facial features. Instead, a nonsurgical E-IDT approach was taken to successfully and wholly resolve her multifaceted disorders. The article reviews conventional treatment options for short-face adult patients and explains modern E-IDT, which may involve a combination of orthodontic therapy, implant treatment, periodontal treatment, and prosthodontic correction.

Characterization of electrophilicity and oxidative potential of atmospheric carbonyls.

Carbonyls are reactive and electrophilic compounds found ubiquitously in the atmosphere. The interactions between atmospheric carbonyls and biological nucleophiles (e.g., thiol-containing compounds) have important implications on their toxicity, but the underlying mechanisms have not been fully understood. In this study, we used combined computational and experimental approaches to assess the reactivities of atmospheric carbonyls in respect to their electrophilic properties. Global electrophilicity indexes (ω) were calculated based on density functional theory. The reactivities of carbonyls with thiols were assessed using the dithiothreitol (DTT) assay as a surrogate of biological nucleophilic antioxidants. The computational results indicated that the ω of a given carbonyl compound is largely influenced by its molecular structure and adjacent functional groups. The calculated ω values showed a strong linear correlation with the logarithm of measured carbonyl mass-normalized DTT consumption rates (r2 = 0.8378 and 0.9899 for simple and α,ß-unsaturated carbonyls, respectively). The removal of DTT through the nucleophilic addition pathway was confirmed by the detection of carbonyl-DTT adducts using the gas chromatography/electron ionization-mass spectrometry (GC/EI-MS) technique. Our results demonstrated that electrophilicity index can be potentially used as a molecular descriptor to predict toxicity of atmospheric carbonyls towards thiol-containing biomolecules. This work also highlights the significance of carbonyls in interpreting DTT-based aerosol oxidative potential.

ReCombine: a suite of programs for detection and analysis of meiotic recombination in whole-genome datasets.

In meiosis, the exchange of DNA between chromosomes by homologous recombination is a critical step that ensures proper chromosome segregation and increases genetic diversity. Products of recombination include reciprocal exchanges, known as crossovers, and non-reciprocal gene conversions or non-crossovers. The mechanisms underlying meiotic recombination remain elusive, largely because of the difficulty of analyzing large numbers of recombination events by traditional genetic methods. These traditional methods are increasingly being superseded by high-throughput techniques capable of surveying meiotic recombination on a genome-wide basis. Next-generation sequencing or microarray hybridization is used to genotype thousands of polymorphic markers in the progeny of hybrid yeast strains. New computational tools are needed to perform this genotyping and to find and analyze recombination events. We have developed a suite of programs, ReCombine, for using short sequence reads from next-generation sequencing experiments to genotype yeast meiotic progeny. Upon genotyping, the program CrossOver, a component of ReCombine, then detects recombination products and classifies them into categories based on the features found at each location and their distribution among the various chromatids. CrossOver is also capable of analyzing segregation data from microarray experiments or other sources. This package of programs is designed to allow even researchers without computational expertise to use high-throughput, whole-genome methods to study the molecular mechanisms of meiotic recombination.

Mapping of crossover sites using DNA microarrays.

Crossovers (COs) play an essential role in promoting successful chromosome segregation during meiosis. Crossing over generates chiasmata, which are physical bridges between homologs that provide the appropriate tension to properly align chromosomes on the meiosis I spindle. Homolog pairs that fail to cross over can result in meiosis I nondisjunction, leading to aneuploid gametes. Therefore, the number and distribution of crossovers are tightly regulated to ensure that each chromosome pair receives at least one CO. Here, we describe a DNA microarray-based method to map CO distribution genome-wide, on a cell-by-cell basis, allowing for rapid and accurate analysis of multiple aspects of CO control.

Global analysis of the meiotic crossover landscape.

Tight control of the number and distribution of crossovers is of great importance for meiosis. Crossovers establish chiasmata, which are physical connections between homologous chromosomes that provide the tension necessary to align chromosomes on the meiotic spindle. Understanding the mechanisms underlying crossover control has been hampered by the difficulty in determining crossover distributions. Here, we present a microarray-based method to analyze multiple aspects of crossover control simultaneously and rapidly, at high resolution, genome-wide, and on a cell-by-cell basis. Using this approach, we show that loss of interference in zip2 and zip4/spo22 mutants is accompanied by a reduction in crossover homeostasis, thus connecting these two levels of crossover control. We also provide evidence to suggest that repression of crossing over at telomeres and centromeres arises from different mechanisms. Lastly, we uncover a surprising role for the synaptonemal complex component Zip1 in repressing crossing over at the centromere.