Physician-hospital alignment: A definition and framework grounded in physicians' perception.

The alignment of physicians' interests with those of their hospital has garnered considerable interest in recent years, in part because of their central role in health care expenditure and patient outcomes. However, the systematic study of physician-hospital alignment is currently impeded by a lack of construct clarity. This is evidenced by research that conflates the actions intended to create alignment with alignment itself. It is also evidenced by a variety of different definitions, conceptualizations, and measures in the literature, most of which are confounded with constructs that are something other than alignment (e.g., commitment, trust). CRITICAL THEORETICAL ANALYSIS: We draw on agency theory and person-organization fit to define physician-hospital alignment as a physician's perception that their financial incentives, goals, and values and those of their hospital are mutually supporting and reinforcing rather than in conflict with one another. ADVANCE: To better understand the nature of the construct and to help guide future research, we present an integrative framework grounded in physicians' perceptions. PRACTICE IMPLICATION: Our definition and framework set the stage for improved construct validation and more systematic study and management of physician-hospital alignment.

Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic.

During the COVID-19 pandemic, frontline nursing home staff faced extraordinary stressors including high infection and mortality rates and ever-changing and sometimes conflicting federal and state regulations. To support nursing homes in evidence-based infection control practices, the Massachusetts Senior Care Association and Hebrew SeniorLife partnered with the Agency for Healthcare Research and Quality AHRQ ECHO National Nursing Home COVID-19 Action Network (the network). This educational program provided 16 weeks of free weekly virtual sessions to 295 eligible nursing homes, grouped into nine cohorts of 30-33 nursing homes. Eighty-three percent of eligible nursing homes in Massachusetts participated in the Network, and Hebrew SeniorLife's Training Center served the vast majority. Each cohort was led by geriatrics clinicians and nursing home leaders, and coaches trained in quality improvement. The interactive sessions provided timely updates on COVID-19 infection control best practices to improve care and also created a peer-to-peer learning community to share ongoing challenges and potential solutions. The weekly Network meetings were a source of connection, emotional support, and validation and may be a valuable mechanism to support resilience and well-being for nursing home staff.

Predictors and Costs of 30-Day Readmissions After Index Hospitalizations for Alcohol-Related Disorders in U.S. Adults.

BACKGROUND: In 2015, the Hospital Readmissions Reduction Program mandated financial penalties to hospitals with greater rates of readmissions for certain conditions. Alcohol-related disorders (ARD) are the fourth leading cause of 30-day readmissions. Yet, there is a dearth of national-level research to identify high-risk patient populations and predictors of 30-day readmission. This study examined patient- and hospital-level predictors for index hospitalizations with principal diagnosis of ARD and predicted the cost of 30-day readmissions. METHODS: The 2014 Nationwide Readmissions Database was used to identify ARD-related index hospitalizations. Multivariable logistic regression was used to estimate patient- and hospital-level predictors for readmissions, and a 2-part model was used to predict the incremental cost conditional upon readmission. RESULTS: In 2014, 285,767 index hospitalizations for ARD were recorded, and 18.9% of ARD-associated hospitalizations resulted in at least one 30-day readmission. Patients who were males, aged 45 to 64 years, Medicaid enrollees, living in urban and low-income areas, or with 1 to 2 comorbidities had high risk of readmission. Index hospitalization costs were higher among readmitted patients ($8,840 vs. $8,036, p < 0.01). Predicted mean costs for readmissions on index stay with ARD were greater among those aged 45 to 64 years ($1,908, p < 0.001), Medicare enrollees ($2,133, p < 0.001), rural residents ($1,841, p < 0.01), living in high-income areas ($1,876, p < 0.001), with 4 or more comorbidities ($2,415, p < 0.001), or admitted in large metropolitan hospitals ($2,032, p < 0.001), with large number of beds ($1,964, p < 0.001), with government ownership ($2,109, p < 0.001), or with low volume of ARD cases ($2,155, p < 0.001). CONCLUSIONS: One in 5 ARD-related index hospitalizations resulted in a 30-day readmission. Overall, costs of index hospitalizations for ARD were $2.3 billion, of which $512 million were spent on hospitalizations that resulted in at least 1 readmission. There is a need to develop patient-centric health programs to reduce readmission rates and costs among ARD patients.

Impact of implementing a technology platform in community pharmacies to increase adult immunizations rates.

Over the course of this project, we utilized pharmacists at 159 community pharmacies in Nebraska and Iowa to administer vaccinations to adults 19 years of age or older with the objective of improving immunization rates in both states. We implemented a pharmacy-based technology platform and partnered with public health via the state immunization registries of both states to ensure that immunizations provided at the pharmacy were transmitted to the statewide registry, for which reporting is currently voluntary for health care providers. After using the technology platform for one year, an increase of immunization rates for influenza, herpes zoster, and pertussis vaccination rates by 37%, 12%, and 74%, respectively, was recorded in comparison to the prior year numbers. However, there was about 16% decrease in vaccination rates for pneumococcal vaccine. For the first time, the project's participating pharmacies in Nebraska reported immunization counts to their state's immunization registries. This project leveraged community pharmacies as healthcare destinations to achieve further gains in increasing immunization rates, improving the health of adults, and creating a community-wide network for prevention.

Wellness programme at the workplace promotes dietary change and improves health indicators in a longitudinal retrospective study.

OBJECTIVE: To determine the effectiveness of a workplace wellness programme intervention in improving participants' behaviour towards choosing a healthy diet and the correlation with health indicators. DESIGN: A retrospective cohort study. SETTING: Wellness programme in the Midwest, USA. SUBJECTS: Employees (n 12 636) who participated in a wellness programme for three consecutive years during years 2004 to 2013 and who completed web-based health risk questionnaires. The wellness programme included annual health screening, laboratory measures, health risk questionnaire and personalized health-care programme. Participants' food group intakes, BMI and health indicators were compared between the first and last year of participation. McNemar's non-parametric test was used for paired nominal data. Pearson correlations were computed for paired food and health indicator measurements. Correlations between dietary intake and BMI, cholesterol and TAG were computed using Pearson correlations and McNemar's test. RESULTS: There were negative correlations between intakes of fruits, vegetables, grains, dairy, healthy eating pattern and health outcome indicators such as BMI and TAG levels. Additionally, the percentage of employees who increased their consumption of fruits (16·88 v. 12·08 %, P<0·001), vegetables (15·20 v. 11·44 %, P<0·001) and dark green leafy vegetables (12·03 v. 7·27 %, P 0·001) was significantly higher than the percentage of participants who decreased their intake of these food groups during the third-year follow-up. CONCLUSIONS: The wellness programme improved some health indicator parameters and had a positive impact on increasing participants' intakes of fruits, vegetables and whole grains at the third year of follow-up.

A needs assessment for simulation-based training of emergency medical providers in Nebraska, USA.

BACKGROUND: Training emergency medical services (EMS) workforce is challenging in rural and remote settings. Moreover, critical access hospitals (CAHs) struggle to ensure continuing medical education for their emergency department (ED) staff. This project collected information from EMS and ED providers across Nebraska to identify gaps in their skills, knowledge, and abilities and thus inform curriculum development for the mobile simulation-based training program. METHODS: The needs assessment used a three-step process: (1) four facilitated focus group sessions were conducted in distinct geographical locations across Nebraska to identify participants' perceived training gaps; (2) based on the findings from the focus group, a needs assessment survey was constructed and sent to all EMS and ED staff in Nebraska; and (3) 1395 surveys were completed and analyzed. RESULTS: Thematic areas of training gaps included cardiopulmonary conditions, diabetes management, mass casualty incidents (MCI), maternal health and child delivery, patient assessment, pediatric care (PC), and respiratory emergency care. Gaps in non-clinical skills were related to crisis management such as maintaining effective teamwork. Participants frequently identified cardiopulmonary care, PC, and MCI as highly needed trainings. Other needs included life support-related retaining courses, sessions informing protocol updates, the availability of retraining tailored for rural areas, substance use-related emergencies, and farming-related injuries. CONCLUSION: EMS and ED staff identified several skill gaps and training needs in the provision of emergency services in rural communities. These results allow for the development of customized training curricula and, with the help of an on-site simulation-based program, can identify gaps in health professionals' skills, knowledge, and abilities and thus help them respond to acute healthcare needs of rural communities.

Hospital-Based Emergency Department Visits With Dental Conditions: Impact of the Medicaid Reimbursement Fee for Dental Services in New York State, 2009-2013.

OBJECTIVES: Hospital-based emergency department (ED) visits for dental problems have been on the rise. The objectives of this study are to provide estimates of hospital-based ED visits with dental conditions in New York State and to examine the impact of Medicaid reimbursement fee for dental services on the utilization of EDs with dental conditions. METHODS: New York State Emergency Department Database for the year 2009-2013 and Health Resources and Services Administration's Area Health Resource File were used. All ED visits with diagnosis for dental conditions were selected for analysis. RESULTS: The present study found a total of 325,354 ED visits with dental conditions. The mean age of patient was 32.4 years. A majority of ED visits were made by those aged 25-44 years (49%). Whites comprised 52.1% of ED visits. Proportion of Medicaid increased from 22% (in 2009) to 41.3% (in 2013). For Medicaid patients, the mean ED charges and aggregated ED charges were $811.4 and $88.1 million, respectively. Eleven counties had fewer than 4 dentists per 10,000 population in New York State. CONCLUSION: High-risk groups identified from the study are those aged 25-44 years, uninsured, covered by Medicaid and private insurance, and residing in low-income areas. The study highlights the need for increased Medicaid reimbursement for dentists and improves access to preventive dental care especially for the vulnerable groups.

Longitudinal associations between body mass index, physical activity, and healthy dietary behaviors in adults: A parallel latent growth curve modeling approach.

BACKGROUND: Physical activity (PA) and healthy dietary behaviors (HDB) are two well-documented lifestyle factors influencing body mass index (BMI). This study examined 7-year longitudinal associations between changes in PA, HDB, and BMI among adults using a parallel latent growth curve modeling (LGCM). METHODS: We used prospective cohort data collected by a private company (SimplyWell LLC, Omaha, NE, USA) implementing a workplace health screening program. Data from a total of 2,579 adults who provided valid BMI, PA, and HDB information for at least 5 out of 7 follow-up years from the time they entered the program were analyzed. PA and HDB were subjectively measured during an annual online health survey. Height and weight measured during an annual onsite health screening were used to calculate BMI (kg·m2). The parallel LGCMs stratified by gender and baseline weight status (normal: BMI<25, overweight BMI 25-29.9, and obese: BMI>30) were fitted to examine the longitudinal associations of changes in PA and HDB with change in BMI over years. RESULTS: On average, BMI gradually increased over years, at rates ranging from 0.06 to 0.20 kg·m2·year, with larger increases observed among those of normal baseline weight status across genders. The increases in PA and HDB were independently associated with a smaller increase in BMI for obese males (b = -1.70 and -1.98, respectively), and overweight females (b = -1.85 and -2.46, respectively) and obese females (b = -2.78 and -3.08, respectively). However, no significant associations of baseline PA and HDB with changes in BMI were observed. CONCLUSIONS: Our study suggests that gradual increases in PA and HDB are independently associated with smaller increases in BMI in overweight and obese adults, but not in normal weight individuals. Further study is warranted to address factors that check increases in BMI in normal weight adults.

Epidemiologic and Clinical Profiles of Breast Diseases in Niger.

This study aimed at characterizing epidemiologic and clinical profiles of breast diseases in Niger during the period of 2010-2013 at the National Hospital of Niamey. Medical records were abstracted for demographic, reproductive, clinical, and treatment information. A process map of patient navigation and barriers to seeking medical care was developed after interviewing 26 local health professionals who encounter and/or manage breast diseases. We identified 245 breast cancers and 122 other breast diseases. Mean age of breast cancer patients was 45.4 (±13.26 years) and that of breast diseases was 31(±12.5 years) with 1/3 of cancers under age 44. Infection-related diseases represented 24% of non-cancers. Male breast diseases represented 4.75% of diseases and 2.05% of cancers. Only 37.1% of cancers had histopathologic confirmation and 90% of cancer patients presented at advanced stages and mastectomy was performed for 66% of breast cancers. Patient and system barriers to care were common in diagnosing and treating breast diseases. Women in Niger have double burden of infectious breast diseases and emerging breast cancer. Younger age and late diagnosis are common features. Reducing barriers to access to care, down-staging of cancer, implementation of clinical guidelines for managing advanced cases are important needs for reducing breast cancer morbidity and mortality in Niger.

Quantitative fluorescence imaging analysis for cancer biomarker discovery: application to beta-catenin in archived prostate specimens.

The surprising disparity between the number of protein-encoding genes ( approximately 30,000) in the human genome and the number of proteins ( approximately 300,000) in the human proteome has inspired the development of translational proteomics aimed at protein expression profiling of disease states. Translational proteomics, which offers the promise of early disease detection and individualized therapy, requires new methods for the analysis of clinical specimens. We have developed quantitative fluorescence imaging analysis (QFIA) for accurate, reproducible quantification of proteins in slide-mounted tissues. The method has been validated for the analysis of beta-catenin in archived prostate specimens fixed in formalin. QFIA takes advantage of the linearity of fluorescence antibody signaling for tissue epitope content, a feature validated for beta-catenin in methacarn-fixed prostate specimens analyzed by reverse-phase protein array analysis and QFIA (r = 0.97). QFIA of beta-catenin in formaldehyde-fixed tissues correlated directly with beta-catenin content (r = 0.86). Application of QFIA in a cross-sectional study of biopsies from 42 prostate cancer (PC) cases and 42 matched controls identified beta-catenin as a potential field marker for PC. Receiver operating characteristic plots revealed that beta-catenin expression in the normal-appearing acini of cancerous glands identified 42% (95% confidence intervals, 26-57%) of cancer cases, with 88% (95% confidence intervals, 80-96%) specificity. The marker may contribute to a PC biomarker panel. In conclusion, we report the development and validation of a new method for fluorescence quantification of proteins in archived tissues and its application to archived specimens for an evaluation of beta-catenin expression as a biomarker for PC.

Pan-cadherin as a high level phenotypic biomarker for prostate cancer.

PURPOSE: High level phenotypic biomarkers such as cadherins are needed to identify individuals at risk for biologically active prostate cancer and determine which individuals with elevated prostate specific antigen or a prostate nodule are candidates for re-biopsy. Cadherins are a high level phenotypic biomarker associated with decreased cell adhesion, which is a cardinal event in carcinogenesis. Recently we reported that G-actin and tissue transglutaminase type II are potential biomarkers for prostate cancer. In this study we present cadherins as a potential third component of the biomarker profile. MATERIALS AND METHODS: Prostate tissues from 38 patients with cancer and 33 controls with a 10-year prostate cancer-free followup were labeled for pan-cadherin by immunohistochemical testing. Immunoreactivity was quantified using a Pathology Workstation (Autocyte Inc., Elon College, North Carolina). RESULTS: Visually benign glands from controls generally expressed cadherins, whereas regions of adenocarcinoma were generally negative. On quantitative immunohistochemistry 36 of 38 prostate cancer cases expressed a lower mean percent area positive for cadherin than the 19 benign prostatic hyperplasia and 14 prostatitis cases (odds ratio 978, 95% confidence interval 45 to 21,140, relative risk 18, 95% confidence interval 5 to 67, p <0.0001). Receiver operating characteristics analysis of immunohistochemical testing data showed that an optimal threshold of 7 produced 95% sensitivity and 100% specificity. CONCLUSIONS: Quantitative down-regulation of cadherin expression in prostate cancer tissue sections is a strong biomarker for prostate cancer. Analysis of cadherin and other high level phenotypic biomarker expression in the premalignant field may provide additional diagnostic information to decide which patients need re-biopsy, more intensive monitoring or chemoprevention.