Social Determinants of Health are Associated with Coping of Informal Caregivers of Adults with Heart Failure.

We explored the influence of social determinants of health (SDH) risk on stress and coping style in heart failure (HF) caregivers. In this cross-sectional study, data from 250 caregivers were analyzed. Multivariable linear regression analyses were performed to determine the extent to which SDH risk (measured using a modified PRAPARE tool (National Association of Community Health Centers), range 0-22) predicted stress (Perceived Stress Scale, 0-56) and coping style (active (0-45), avoidance (0-30), and minimization (0-30)) while accounting for caregiver burden (HF Caregiver Questionnaire (HF-CQ) 0-100). Multivariable regression analysis with backwards elimination variable selection approach was used to identify which SDH risk factors best predicted coping styles. SDH risk was significantly associated with avoidance and minimization coping styles. Each unit increase in SDH risk was associated with an increase of 0.6 ± 0.2 units (p = .0008) in avoidance and 0.7 ± 0.2 units (p < .0001) in minimization coping style. Race and "supporting others" significantly predicted avoidance coping style; scores were 3.3 ± 0.8 units greater for caregivers who were not White (p < .0001) and 1.4 ± 0.5 units greater (p < .01) for each additional person whom they supported. Race significantly predicted minimization coping style; scores were 4.4 ± 0.7 units greater for caregivers who were not White (p < .0001). Caregivers with higher SDH risk may avoid and minimize to cope with caregiving challenges.

Measuring collective behavior: an ecological approach.

Collective behavior is ubiquitous throughout nature. Many systems, from brains to ant colonies, work without central control. Collective behavior is regulated by interactions among the individual participants such as neurons or ants. Interactions create feedback that produce the outcome, the behavior that we observe: Brains think and remember, ant colonies collect food or move nests, flocks of birds turn, human societies develop new forms of social organization. But the processes by which interactions produce outcomes are as diverse as the behavior itself. Just as convergent evolution has led to organs, such as the eye, that are similar in function but are based on different physiological processes, so it has led to forms of collective behavior that appear similar but arise from different social processes. An ecological perspective can help us to understand the dynamics of collective behavior and how it works.

Prevalence of Financial Considerations Documented in Primary Care Encounters as Identified by Natural Language Processing Methods.

Importance: Quantifying patient-physician cost conversations is challenging but important as out-of-pocket spending by US patients increases and patients are increasingly interested in discussing costs with their physicians. Objective: To characterize the prevalence of financial considerations documented in narrative clinical records of primary care encounters and their association with patient-level features. Design, Setting, and Participants: This cohort study applied natural language processing to narrative clinical notes obtained from electronic health records for adult primary care visits. Participants included patients aged 18 years and older with at least 1 primary care visit for an annual preventive examination at outpatient clinics at a US academic health system between January 2, 2008, and July 30, 2013. Data were analyzed in March 2019. Main Outcomes and Measures: Presence of financial content documented in narrative clinical notes. Results: The data set included 222 457 primary care visits for 46 244 individuals aged 18 years and older; 30 556 patients (60.1%) were female, 27 869 patients (60.3%) were white, and the mean (SD) age was 51.3 (17.7) years. In total, 6058 patients (13.1%) had at least 1 narrative clinical note indicating a financial conversation with their physician. In fully adjusted regression models, the odds of having a financial note were greater among patients with Medicare (odds ratio [OR], 1.27; 95% CI, 1.15-1.41; P < .001) or Medicaid (OR, 1.43; 95% CI, 1.25-1.64; P < .001) insurance, those residing in zip codes with lower median income (OR, 0.97; 95% CI, 0.96-0.98; P < .001), black individuals (OR, 1.40; 95% CI, 1.28-1.53; P < .001), Hispanic individuals (OR, 1.10; 95% CI, 1.01-1.20; P = .03), and those who were unmarried (OR, 1.23; 95% CI, 1.15-1.33; P < .001). Conclusions and Relevance: Cost considerations were more likely to be noted in annual preventive examinations than previously observed in intensive care unit admissions, but still infrequently. Associations with particular patient subgroups may indicate differential financial burden or willingness to discuss financial concerns.

Medicare for All Should Not Be One Size Fits All.

For Medicare for all to truly work for all Americans it must do more than provide uniform, basic insurance. In health care, as in fashion, consumers need different options. To truly reform health care, solutions must allow customization and consumer choice.

Prevalence and Nature of Financial Considerations Documented in Narrative Clinical Records in Intensive Care Units.

Importance: The extent to which financial considerations alter intensive care unit (ICU) decision making is poorly understood. Objectives: To characterize the prevalence and nature of financial considerations documented in narrative clinical records and their association with patient-level demographic and clinical features. Design, Setting, and Participants: In silico cohort study applying natural language processing to narrative notes from the Medical Information Mart for Intensive Care (MIMIC-III) study. Data from all individuals hospitalized between June 1, 2001, and October 31, 2012, in the ICU of Beth Israel Deaconess Medical Center were analyzed from April 1 to April 30, 2018. Main Outcomes and Measure: Presence of financial considerations in narrative clinical notes. Results: Among 46 146 index ICU admissions, 1936 patients (4.2%) were identified with at least 1 note reflecting financial considerations during the ICU stay. Of these 1936 patients, 1135 (58.6%) were male, with a mean (SD) age of 38.8 (28.4) years and mean (SD) length of stay of 21.7 (27.1) days. Among the remaining 44 210 admissions in the cohort, 24 780 (56.1%) were male, with a mean (SD) age of 48.6 (32.1) years and mean (SD) length of stay of 9.2 (11.4) days. Among the 46 146 admissions, 142 (0.3%) included notes describing a change in the discharge plan, 142 (0.3%) describing a change in the treatment plan, and 303 (0.7%) describing a change in medication or previous nonadherence to medication associated with financial considerations. In logistic regression models adjusted for age, sex, marital status, and insurance type, longer hospital stays were significantly associated with the presence of financial notes (odds ratio, 1.01; 95% CI, 1.01-1.01). Conclusions and Relevance: In this study, among patients in the ICU, clinical notes document the association of financial considerations with care decisions. Although such notes likely underestimate the frequency of such considerations, they highlight the need to develop better systematic approaches to understanding how financial constraints may alter care decisions in US health systems.

Hemovigilance in Massachusetts and the adoption of statewide hospital blood bank reporting using the National Healthcare Safety Network.

A collaboration that grew over time between local hemovigilance stakeholders and the Massachusetts Department of Public Health (MDPH) resulted in the change from a paper-based method of reporting adverse reactions and monthly transfusion activity for regulatory compliance purposes to statewide adoption of electronic reporting via the National Healthcare Safety Network (NHSN). The NHSN is a web-based surveillance system that offers the capacity to capture transfusion-related adverse events, incidents, and monthly transfusion statistics from participating facilities. Massachusetts' hospital blood banks share the data they enter into NHSN with the MDPH to satisfy reporting requirements. Users of the NHSN Hemovigilance Module adhere to specified data entry guidelines, resulting in data that are comparable and standardized. Keys to successful statewide adoption of this reporting method include the fostering of strong partnerships with local hemovigilance champions and experts, engagement of regulatory and epidemiology divisions at the state health department, the leveraging of existing relationships with hospital NHSN administrators, and the existence of a regulatory deadline for implementation. Although limitations exist, successful implementation of statewide use of the NHSN Hemovigilance Module for hospital blood bank reporting is possible. The result is standardized, actionable data at both the hospital and state level that can facilitate interfacility comparisons, benchmarking, and opportunities for practice improvement.

Energy Return on Investment (EROI) for Forty Global Oilfields Using a Detailed Engineering-Based Model of Oil Production.

Studies of the energy return on investment (EROI) for oil production generally rely on aggregated statistics for large regions or countries. In order to better understand the drivers of the energy productivity of oil production, we use a novel approach that applies a detailed field-level engineering model of oil and gas production to estimate energy requirements of drilling, producing, processing, and transporting crude oil. We examine 40 global oilfields, utilizing detailed data for each field from hundreds of technical and scientific data sources. Resulting net energy return (NER) ratios for studied oil fields range from ≈2 to ≈100 MJ crude oil produced per MJ of total fuels consumed. External energy return (EER) ratios, which compare energy produced to energy consumed from external sources, exceed 1000:1 for fields that are largely self-sufficient. The lowest energy returns are found to come from thermally-enhanced oil recovery technologies. Results are generally insensitive to reasonable ranges of assumptions explored in sensitivity analysis. Fields with very large associated gas production are sensitive to assumptions about surface fluids processing due to the shifts in energy consumed under different gas treatment configurations. This model does not currently include energy invested in building oilfield capital equipment (e.g., drilling rigs), nor does it include other indirect energy uses such as labor or services.

Cost effectiveness analysis for nursing research.

BACKGROUND: With ever-increasing pressure to reduce costs and increase quality, nurses are faced with the challenge of producing evidence that their interventions and care provide value. Cost effectiveness analysis (CEA) is a tool that can be used to provide this evidence by comparative evaluation of the costs and consequences of two or more alternatives. OBJECTIVES: The aim of this article is to introduce the essential components of CEA to nurses and nurse researchers with the protocol of a recently funded cluster randomized controlled trial as an example. METHODS: This article provides (a) a description of the main concepts and key steps in CEA and (b) a summary of the background and objectives of a CEA designed to evaluate a nursing-led pain and symptom management intervention in rural communities compared with the current usual care. DISCUSSION: As the example highlights, incorporating CEA into nursing research studies is feasible. The burden of the additional data collection required is offset by quantitative evidence of the given intervention's cost and impact using humanistic and economic outcomes. At a time when U.S. healthcare is moving toward accountable care, the information provided by CEA will be an important additional component of the evidence produced by nursing research.

Squeezing the funding you need from today's capital sources.

Healthcare providers need to understand traditional and nontraditional financing options and other potential strategies for accessing capital. Common financing options include bonds, commercial lending, acquisition financing, and financing through the Department of Housing and Urban Development's Section 232 program. Alternative strategies for accessing capital include joint ventures, equity, sale of assets, fund-raising, capital leases, internal capital, public grants, and grants from foundations.

The devil to pay: a cost of mutualism with Myrmelachista schumanni ants in 'devil's gardens' is increased herbivory on Duroia hirsuta trees.

'Devil's gardens' are nearly pure stands of the myrmecophyte, Duroia hirsuta, that occur in Amazonian rainforests. Devil's gardens are created by Myrmelachista schumanni ants, which nest in D. hirsuta trees and kill other plants using formic acid as an herbicide. Here, we show that this ant-plant mutualism has an associated cost; by making devil's gardens, M. schumanni increases herbivory on D. hirsuta. We measured standing leaf herbivory on D. hirsuta trees and found that they sustain higher herbivory inside than outside devil's gardens. We also measured the rate of herbivory on nursery-grown D. hirsuta saplings planted inside and outside devil's gardens in ant-exclusion and control treatments. We found that when we excluded ants, herbivory on D. hirsuta was higher inside than outside devil's gardens. These results suggest that devil's gardens are a concentrated resource for herbivores. Myrmelachista schumanni workers defend D. hirsuta against herbivores, but do not fully counterbalance the high herbivore pressure in devil's gardens. We suggest that high herbivory may limit the spread of devil's gardens, possibly explaining why devil's gardens do not overrun Amazonian rainforests.

Task-specific expression of the foraging gene in harvester ants.

In social insects, groups of workers perform various tasks such as brood care and foraging. Transitions in workers from one task to another are important in the organization and ecological success of colonies. Regulation of genetic pathways can lead to plasticity in social insect task behaviour. The colony organization of advanced eusocial insects evolved independently in ants, bees, and wasps and it is not known whether the genetic mechanisms that influence behavioural plasticity are conserved across species. Here we show that a gene associated with foraging behaviour is conserved across social insect species, but the expression patterns of this gene are not. We cloned the red harvester ant (Pogonomyrmex barbatus) ortholog (Pbfor) to foraging, one of few genes implicated in social organization, and found that foraging behaviour in harvester ants is associated with the expression of this gene; young (callow) worker brains have significantly higher levels of Pbfor mRNA than foragers. Levels of Pbfor mRNA in other worker task groups vary among harvester ant colonies. However, foragers always have the lowest expression levels compared to other task groups. The association between foraging behaviour and the foraging gene is conserved across social insects but ants and bees have an inverse relationship between foraging expression and behaviour.