Giant pyroelectricity in nanomembranes.

Pyroelectricity describes the generation of electricity by temporal temperature change in polar materials1-3. When free-standing pyroelectric materials approach the 2D crystalline limit, how pyroelectricity behaves remained largely unknown. Here, using three model pyroelectric materials whose bonding characters along the out-of-plane direction vary from van der Waals (In2Se3), quasi-van der Waals (CsBiNb2O7) to ionic/covalent (ZnO), we experimentally show the dimensionality effect on pyroelectricity and the relation between lattice dynamics and pyroelectricity. We find that, for all three materials, when the thickness of free-standing sheets becomes small, their pyroelectric coefficients increase rapidly. We show that the material with chemical bonds along the out-of-plane direction exhibits the greatest dimensionality effect. Experimental observations evidence the possible influence of changed phonon dynamics in crystals with reduced thickness on their pyroelectricity. Our findings should stimulate fundamental study on pyroelectricity in ultra-thin materials and inspire technological development for potential pyroelectric applications in thermal imaging and energy harvesting.

Assessment of Variation in Electronic Health Record Capabilities and Reported Clinical Quality Performance in Ambulatory Care Clinics, 2014-2017.

Importance: Electronic health records (EHRs) are widely promoted to improve the quality of health care, but information about the association of multifunctional EHRs with broad measures of quality in ambulatory settings is scarce. Objective: To assess the association between EHRs with different degrees of capabilities and publicly reported ambulatory quality measures in at least 3 clinical domains of care. Design, Setting, and Participants: This cross-sectional and longitudinal study was conducted using survey responses from 1141 ambulatory clinics in Minnesota, Washington, and Wisconsin affiliated with a health system that responded to the Healthcare Information and Management Systems Society Annual Survey and reported performance measures in 2014 to 2017. Statistical analysis was performed from July 10, 2019, through February 26, 2021. Main Outcomes and Measures: A composite measure of EHR capability that considered 50 EHR capabilities in 7 functional domains, grouped into the following ordered categories: no functional EHR, EHR underuser, EHR, neither underuser or superuser, EHR superuser; as well as a standardized composite of ambulatory clinical performance measures that included 3 to 25 individual measures (median, 13 individual measures). Results: In 2014, 381 of 746 clinics (51%) were EHR superusers; this proportion increased in each subsequent year (457 of 846 clinics [54%] in 2015, 510 of 881 clinics [58%] in 2016, and 566 of 932 clinics [61%] in 2017). In each cross-sectional analysis year, EHR superusers had better clinical quality performance than other clinics (adjusted difference in score: 0.39 [95% CI, 0.12-0.65] in 2014; 0.29 [95% CI, -0.01 to 0.59] in 2015; 0.26 [95% CI, -0.05 to 0.56] in 2016; and 0.20 [95% CI, -0.04 to 0.45] in 2017). This difference in scores translates into an approximately 9% difference in a clinic's rank order in clinical quality. In longitudinal analyses, clinics that progressed to EHR superuser status had only slightly better gains in clinical quality between 2014 and 2017 compared with the gains in clinical quality of clinics that were static in terms of their EHR status (0.10 [95% CI, -0.13 to 0.32]). In an exploratory analysis, different types of EHR capability progressions had different degrees of associated improvements in ambulatory clinical quality (eg, progression from no functional EHR to a status short of superuser, 0.06 [95% CI, -0.40 to 0.52]; progression from EHR underuser to EHR superuser, 0.18 [95% CI, -0.14 to 0.50]). Conclusions and Relevance: Between 2014 and 2017, ambulatory clinics in Minnesota, Washington, and Wisconsin with EHRs having greater capabilities had better composite measures of clinical quality than other clinics, but clinics that gained EHR capabilities during this time had smaller increases in clinical quality that were not statistically significant.

Mandated Benefits for Diabetes Education and the Availability of Accredited Programs and Certified Diabetes Educators.

States have the latitude to mandate coverage of diabetes self-management education (DSME) services for privately insured and Medicaid patients. The impact of these mandates on the supply of DSME resources is unknown. This study compared changes in the supply of DSME programs and program sites accredited by the American Association for Diabetes Educators (AADE) and certified diabetes educators (CDE) between states that did and did not mandate benefits for DSME. Using a unique combination of legal and programmatic data sources, the authors employed fixed effects regression models with clustered robust standard errors to compare changes in the supply of AADE-accredited DSME programs, program sites, and CDEs in states that mandated benefits with states that did not. Given the variation in state mandates, models also estimated the impact of "flexible" reimbursement provisions on the supply of resources among adopting states. The supply of DSME resources has increased over time, but results indicate that mandated benefits were not a significant driver of these changes in the supply. The impact of flexible reimbursement provisions varied. Interestingly, provisions of the Affordable Care Act were associated with an increased supply of resources. Results suggest that extending benefits to previously insured patients does not increase the supply of DSME resources, but a rapid increase in patients entering the health system does encourage growth.

Opioid misuse, labor market outcomes, and means-tested public expenditures: a conceptual framework.

As the opioid epidemic has drawn increased attention, many researchers are attempting to estimate the financial burden of opioid misuse. These estimates have become particularly relevant as state and local governments have begun to take legal action against pharmaceutical manufacturers, distributors, and others who are identified as being potentially responsible for the worsening epidemic. An important category of costs includes those related to the effect of opioid misuse on labor market outcomes and productivity. Most published estimates of opioid-attributable productivity losses estimate the financial burden borne by society, failing to distinguish between costs internalized by individuals and those that spill over to third parties, such as state and federal governments. This article provides an overview and a conceptual framework for 2 types of labor market-related costs borne by state and federal governments that typically have not been incorporated into existing estimates, which may represent important categories of expenditures. Because detailed estimates of lost tax revenue are available elsewhere, this article focuses largely on whether, and how, to incorporate opioid-related expenses incurred by means-tested government programs into more general estimates of the economic harm created by the opioid epidemic.

Dissemination of quality improvement innovations by multisector health care alliances.

PURPOSE: Multisector health care alliances (alliances) are increasingly viewed as playing an important role in improving the health and health care of local populations, in part by disseminating innovative practices, yet alliances face a number of challenges to disseminating these practices beyond a limited set of initial participants. The purpose of this paper is to examine how alliances attempt to disseminate innovative practices and the facilitating and inhibiting factors that alliances confront when trying to do so. DESIGN/METHODOLOGY/APPROACH: The authors adopted multiple holistic case study design of eight alliances with a maximum variation case selection strategy to reflect a range of structural and geographic characteristics. Semi-structured interviews with staff, leaders and board members were used. FINDINGS: The findings show that dissemination is a multidirectional process that is closely if not inextricably intertwined with capacity- and context-related factors (of the alliance, partnering organizations and target organizations). Thus, standardized approaches to dissemination are likely the exception and not the rule, and highlight the value of existing frameworks as a starting point for conceptualizing the important aspects of dissemination, but they are incomplete in their description of the "on-the-ground" dissemination processes that occur in the context of collaborative organizational forms such as alliances. ORIGINALITY/VALUE: Despite a rapidly expanding evidence base to guide clinical and managerial decision making, this knowledge often fails to make its way into routine practice. Consequently, the search for effective strategies to reduce this gap has accelerated in the past decade. This study sheds light on those strategies and the challenges to implementing them.

Revenue Losses to State and Federal Government From Opioid-related Employment Reductions.

OBJECTIVE: The main purpose of this study was to estimate the tax revenue lost by state and federal governments as a result of adverse labor market outcomes attributable to opioid misuse. METHODS: We pair existing, plausibly causal estimates of the effect of opioid misuse on the decline in the labor force from 2000 to 2016 with a variety of data sources to compute tax revenues lost by state and federal governments using the online TAXSIM calculator. RESULTS: We find that between 2000 and 2016, opioid misuse cost state governments $11.8 billion, including $1.7 billion in lost sales tax revenue and $10.1 billion in lost income tax revenue. In addition, the federal government lost $26.0 billion in income tax revenue. CONCLUSIONS: By omitting lost tax revenue due to labor force exits, prior studies have missed an important component of opioid-related costs borne by state and federal governments. POLICY IMPLICATIONS: As more states and the federal government contemplate litigation for opioid-related damages, lost tax revenue represents an important cost that could be recouped and allocated to opioid prevention and treatment programs.

Funding profiles of multisector health care alliances and their positioning for sustainability.

Purpose The purpose of this paper is to examine the relationship between different aspects of alliance funding profiles (e.g. range of sources, dependence on specific sources) and participant' perceptions of how well the organization is positioned for the future. Design/methodology/approach A mixed method study in the context of eight alliances participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality program. Data collection approaches included surveys of alliance participants and semi-structured interviews with alliance leaders. Findings The findings indicate that dependence on grant revenues, in particular, may be problematic for how well alliances are positioned for sustainability. While a number of approaches were identified to reduce dependence on grants, implementing these strategies presented more of a challenge for alliances due to the contextual demands of their external environment and a need to strike a balance between pursuing alternative revenue sources and fidelity to the mission and identity of the organization. Practical implications Alliance leaders need to have not only a broad and accurate understanding of their external environment, but also an appreciation of the alliance's identity in that environment. Collectively, the findings can help organizational leaders be more informed about their funding choices and the implications those choices have for the future of their organization. Originality/value Collaborative forms of organizations (e.g. alliances, coalitions, networks) are increasingly viewed as an effective means of addressing complex, multifaceted health, and social challenges. For collaborative organizations that depend on the coordinated efforts of volunteers, addressing such complex issues is predicated on sustaining programmatic activities as well as the interest and participation of stakeholders over extended periods of time. This study sheds light on how leaders of these organizations may improve their prospects for sustainability.

Evaluating a complex, multi-site, community-based program to improve healthcare quality: the summative research design for the Aligning Forces for Quality initiative.

OBJECTIVE: The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed. STUDY DESIGN: A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided. METHODS: The summative research design employed by the evaluation team is discussed. RESULTS: The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program. CONCLUSION: The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

Summative evaluation results and lessons learned from the Aligning Forces for Quality program.

OBJECTIVE: To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015. METHODS: This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities. RESULTS: Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

The longitudinal impact of Aligning Forces for Quality on measures of population health, quality and experience of care, and cost of care.

OBJECTIVE: To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative. STUDY DESIGN: Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care. DATA: Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). RESULTS: In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.

From rhetoric to reality: consumer engagement in 16 multi-stakeholder alliances.

OBJECTIVE: A key component of the Aligning Forces for Quality (AF4Q) program was engaging consumers in their health and healthcare. We examined the extent to which the alliances embraced 4 areas of consumer engagement: self-management, consumer friendliness of reports of healthcare provider quality, involvement of consumers in alliance governance, and the integration of consumers into quality improvement teams. METHODS: We used a largely qualitative approach. The evaluation team conducted 1100 in-depth interviews with alliance stakeholders. Two authors reviewed the consumer engagement data for each alliance to assess its level of embrace in the 4 consumer engagement areas. For consumer friendliness of public reporting websites, we also assessed alliance public reports for reading level, technical language, and evaluable displays. Population-level effects were also examined for self-management and public reporting. RESULTS: Consumer engagement was new to most alliances, and few had staff with consumer engagement expertise or existing consumer constituencies. For each area of consumer engagement, some alliances enthusiastically embraced the work, other alliances made a concerted but limited effort to develop programs, and a third group of alliances did the minimum work required. Integrating consumers into governance was the area most often embraced, followed by making public reports consumer friendly. Two alliances strongly embraced both self-management and integrating patients into quality improvement efforts. The AF4Q program did not have greater population level effects from self-management or public reporting than were those observed in a national comparison sample. CONCLUSION: The AF4Q program sparked a few alliances to develop robust consumer engagement programming, while most alliances tried consumer engagement efforts for the first time and developed an appreciation for integrating consumer perspectives into their work.

Using multi-stakeholder alliances to accelerate the adoption of health information technology by physician practices.

BACKGROUND: Multi-stakeholder alliances - groups of payers, purchasers, providers, and consumers that work together to address local health goals - are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities. METHODS: Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 - March 2009 and January 2012-November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients' online access to their medical records. RESULTS: Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients' online access to medical records between AF4Q and non-AF4Q communities. CONCLUSION: By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients' online access to medical records. IMPLICATIONS: Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

Patient Experience Of Provider Refusal Of Medicaid Coverage And Its Implications.

Previous studies show that many physicians do not accept new patients with Medicaid coverage, but no study has examined Medicaid enrollees' actual experience of provider refusal of their coverage and its implications. Using the 2012 National Health Interview Survey, we estimate provider refusal of health insurance coverage reported by 23,992 adults with continuous coverage for the past 12 months. We find that among Medicaid enrollees, 6.73% reported their coverage being refused by a provider in 2012, a rate higher than that in Medicare and private insurance by 4.07 (p<.01) and 3.68 (p<.001) percentage points, respectively. Refusal of Medicaid coverage is associated with delaying needed care, using emergency room (ER) as a usual source of care, and perceiving current coverage as worse than last year. In view of the Affordable Care Act's (ACA) Medicaid expansion, future studies should continue monitoring enrollees' experience of coverage refusal.

Patient-Centered Medical Home Adoption: Results From Aligning Forces For Quality.

To improve health care quality within communities, increasing numbers of multistakeholder alliances-groups of payers, purchasers, providers, and consumers-have been created. We used data from two rounds (conducted in July 2007-March 2009 and January 2012-November 2013) of a large nationally representative survey of small and medium-size physician practices. We examined whether the adoption of patient-centered medical home processes spread more rapidly in fourteen Robert Wood Johnson Foundation Aligning Forces for Quality communities, where multistakeholder health care alliances promoted their use, than in other communities. We found no difference in the overall growth of adoption of the processes between the two types of communities. However, improvement on a care coordination subindex was 7.17 percentage points higher in Aligning Forces for Quality communities than in others. Despite the enthusiasm for quality improvement led by multistakeholder alliances, such alliances may not be a panacea for spreading patient-centered medical home processes across a community.

Who's Aware of and Using Public Reports of Provider Quality?

Public reporting of health care provider quality is intended to spark consumer informed decision-making, yet there is concern that it might exacerbate disparities. This study explores the extent to which people with chronic conditions are aware of and using comparative quality information (CQI) on hospitals and doctors, and how awareness and use of the information differs by individuals' socio-demographic characteristics. Using a large 2011/2012 survey of adults with chronic conditions, we find low awareness of hospital and doctor CQI (26% and 16% respectively), and lower CQI use (8% and 6% respectively). Findings related to equity in awareness and use by socio-demographic subgroups was mixed. Higher education and income were related to greater CQI awareness, however Whites were less likely to be aware of and use CQI than African Americans and Latinos. The magnitudes of these differences, however, were not large; all groups had modest levels of CQI awareness and use.

Assessing organizational change in multisector community health alliances.

OBJECTIVE: The purpose of this article was to identify some common organizational features of multisector health care alliances (MHCAs) and the analytic challenges presented by those characteristics in assessing organizational change. DATA SOURCES: Two rounds of an Internet-based survey of participants in 14 MHCAs. STUDY DESIGN: We highlight three analytic challenges that can arise when quantitatively studying the organizational characteristics of MHCAs-assessing change in MHCA organization, assessment of construct reliability, and aggregation of individual responses to reflect organizational characteristics. We illustrate these issues using a leadership effectiveness scale (12 items) validated in previous research and data from 14 MHCAs participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program. FINDINGS: High levels of instability and turnover in MHCA membership create challenges in using survey data to study changes in key organizational characteristics of MHCAs. We offer several recommendations to diagnose the source and extent of these problems.

Leadership transitions in multisectoral health care alliances: Implications for member perceptions of participation value.

BACKGROUND: Collaborative forms of organizations such as multisectoral health care alliances play an increasingly prominent role in the U.S. health care system. A key feature of these organizations highlighted in previous research is leadership, yet little research has examined what happens when there is a change in leadership. PURPOSE: The aim of this study was to examine the relationship between leadership transitions in an alliance and member assessments of the benefits and costs of participation, indicators of the value that members derive from their involvement in the alliance. METHODOLOGY/APPROACH: The study used quantitative data collected from three rounds of surveys of alliance members participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality Program. Qualitative interview data supplemented this analysis by providing examples of why leadership transitions may affect participation benefits and costs. FINDINGS: Quantitative analysis indicated that alliance members who experienced a change in leadership reported both higher and lower levels of participation benefits and costs, depending on the type of leadership change (i.e., alliance leader vs. programmatic leader). Qualitative analysis suggested that the scope of responsibilities of different types of leaders plays an important role in how members perceive changes. Likewise, interviews indicated that timing influences how disruptive a leadership transition is and whether it is perceived positively or negatively. PRACTICE IMPLICATIONS: Leadership transitions present both challenges and opportunities; whether the effects are felt positively or negatively depends on when a transition occurs and how it is handled by incoming leaders and remaining members. Furthermore, different types of members report higher levels of participation benefits and lower levels of participation costs, suggesting that efforts to maintain a sense of alliance value during times of transitions may be able to target certain types of individuals.

Seeking health information online: does limited healthcare access matter?

Consumers facing barriers to healthcare access may use online health information seeking and online communication with physicians, but the empirical relationship has not been sufficiently analyzed. Our study examines the association of barriers to healthcare access with consumers' health-related information searching on the internet, use of health chat groups, and email communication with physicians, using data from 27,210 adults from the 2009 National Health Interview Survey. Individuals with financial barriers to healthcare access, difficulty getting timely appointments with doctors, and conflicts in scheduling during clinic hours are more likely to search for general health information online than those without these access barriers. Those unable to get timely appointments with physicians are more likely to participate in health chat groups and email physicians. The internet may offer a low-cost source of health information and could help meet the heightened demand for health-related information among those facing access barriers to care.

Racial-ethnic disparities in use of antidepressants in private coverage: implications for the Affordable Care Act.

OBJECTIVE: The objective of this study was to examine racial-ethnic disparities in the use of antidepressants among people with private coverage and people with public insurance or no coverage. METHODS: Data were from Medical Expenditure Panel Surveys (2006-2010), and logistic regression was used for the analysis. RESULTS: Among persons with depression and private coverage, racial-ethnic minority groups were significantly less likely than non-Hispanic whites to use antidepressants (N=4,468; adjusted odds ratio [AOR]=.50, 95% confidence interval [CI]=.33-.66 for non-Hispanic blacks; AOR=.70, CI=.55-.89 for Hispanics). No significant racial-ethnic disparity in the use of antidepressants was found in Medicare (N=1,944), Medicaid (N=2,125), and uninsured populations (N=1,679). For all racial-ethnic groups, persons with no insurance coverage had much lower rates of antidepressant use than their insured counterparts. CONCLUSIONS: A wide racial-ethnic gap in the use of antidepressants existed in private coverage. As the nation continues to implement the Affordable Care Act, which will increase the number of enrollees from racial-ethnic minority groups in private plans, continuing efforts will be needed to reduce racial-ethnic disparities in the use of antidepressants.