Collective events and individual affect shape autobiographical memory.

How do collective events shape how we remember our lives? We leveraged advances in natural language processing as well as a rich, longitudinal assessment of 1,000 Americans throughout 2020 to examine how memory is influenced by two prominent factors: surprise and emotion. Autobiographical memory for 2020 displayed a unique signature: There was a substantial bump in March, aligning with pandemic onset and lockdowns, consistent across three memory collections 1 y apart. We further investigated how emotion, using both immediate and retrieved measures, predicted the amount and content of autobiographical memory: Negative affect increased recall across all measures, whereas its more clinical indices, depression and posttraumatic stress disorder, selectively increased nonepisodic recall. Finally, in a separate cohort, we found pandemic news to be better remembered, surprising, and negative, while lockdowns compressed remembered time. Our work connects laboratory findings to the real world and delineates the effects of acute versus clinical signatures of negative emotion on memory.

Neurons of Macaque Frontal Eye Field Signal Reward-Related Surprise.

The frontal eye field (FEF) plays a well-established role in the control of visual attention. The strength of an FEF neuron's response to a visual stimulus presented in its receptive field is enhanced if the stimulus captures spatial attention by virtue of its salience. A stimulus can be rendered salient by cognitive factors as well as by physical attributes. These include surprise. The aim of the present experiment was to determine whether surprise-induced salience would result in enhanced visual-response strength in the FEF. Toward this end, we monitored neuronal activity in two male monkeys while presenting first a visual cue predicting with high probability that the reward delivered at the end of the trial would be good or bad (large or small) and then a visual cue announcing the size of the impending reward with certainty. The second cue usually confirmed but occasionally violated the expectation set up by the first cue. Neurons responded more strongly to the second cue when it violated than when it confirmed expectation. The increase in the firing rate was accompanied by a decrease in spike-count correlation as expected from capture of attention. Although both good surprise and bad surprise induced enhanced firing, the effects appeared to arise from distinct mechanisms as indicated by the fact that the bad-surprise signal appeared at a longer latency than the good-surprise signal and by the fact that the strength of the two signals varied independently across neurons.

Early Action Error Processing Is Due to Domain-General Surprise, Whereas Later Processing Is Error Specific.

The ability to adapt behavior after erroneous actions is one of the key aspects of cognitive control. Error commission typically causes people to slow down their subsequent actions [post-error slowing (PES)]. Recent work has challenged the notion that PES reflects adaptive, controlled processing and instead suggests that it is a side effect of the surprising nature of errors. Indeed, human neuroimaging suggests that the brain networks involved in processing errors overlap with those processing error-unrelated surprise, calling into question whether there is a specific system for error processing in the brain at all. In the current study, we used EEG decoding and a novel behavioral paradigm to test whether there are indeed unique, error-specific processes that contribute to PES beyond domain-general surprise. Across two experiments in male and female humans (N = 76), we found that both errors and error-unrelated surprise were followed by slower responses when response-stimulus intervals were short. Furthermore, the early neural processes following error-specific and domain-general surprise showed significant cross-decoding. However, at longer intervals, which provided additional processing time, only errors were still followed by post-trial slowing. Furthermore, this error-specific PES effect was reflected in sustained neural activity that could be decoded from that associated with domain-general surprise, with the strongest contributions found at lateral frontal, occipital, and sensorimotor scalp sites. These findings suggest that errors and surprise initially share common processes, but that after additional processing time, unique, genuinely error-specific processes take over and contribute to behavioral adaptation.SIGNIFICANCE STATEMENT Humans typically slow their actions after errors (PES). Some suggest that PES is a side effect of the unexpected, surprising nature of errors, challenging the notion of a genuine error processing system in the human brain. Here, we used multivariate EEG decoding to identify behavioral and neural processes uniquely related to error processing. Action slowing occurred following both action errors and error-unrelated surprise when time to prepare the next response was short. However, when there was more time to react, only errors were followed by slowing, further reflected in sustained neural activity. This suggests that errors and surprise initially share common processing, but that after additional time, error-specific, adaptive processes take over.

Auditory oddball responses in the human subthalamic nucleus and substantia nigra pars reticulata.

The auditory oddball is a mainstay in research on attention, novelty, and sensory prediction. How this task engages subcortical structures like the subthalamic nucleus and substantia nigra pars reticulata is unclear. We administered an auditory OB task while recording single unit activity (35 units) and local field potentials (57 recordings) from the subthalamic nucleus and substantia nigra pars reticulata of 30 patients with Parkinson's disease undergoing deep brain stimulation surgery. We found tone modulated and oddball modulated units in both regions. Population activity differentiated oddball from standard trials from 200 ms to 1000 ms after the tone in both regions. In the substantia nigra, beta band activity in the local field potential was decreased following oddball tones. The oddball related activity we observe may underlie attention, sensory prediction, or surprise-induced motor suppression.

Financial Viability of the No Surprises Act Independent Dispute Resolution Process: Radiology and Other Hospital-Based Specialties.

BACKGROUND. The federal No Surprises Act (NSA), designed to eliminate surprise medical billing for out-of-network (OON) care for circumstances beyond patients' control, established the independent dispute resolution (IDR) process to settle clinician-payer payment disputes for OON care. OBJECTIVE. The purpose of our study was to assess the fraction of OON claims for which radiologists and other hospital-based specialists can expect to at least break even when challenging payer-determined payments through the NSA IDR process, as a measure of the process's financial viability. METHODS. This retrospective study extracted claims from a national commercial database (Optum's deidentified Clinformatics Data Mart) for hospital-based specialties occurring on the same day as in-network emergency department (ED) visits or inpatient stays from January 2017 to December 2021. OON claims were identified. OON claims batching was simulated using IDR rules. Maximum potential recovered payments from the IDR process were estimated as the difference between the charges and the allowed amount. The percentages of claims for which the maximum potential payment and one-quarter of this amount (a more realistic payment recovery estimate) would exceed IDR fees were determined, using US$150 and US$450 fee thresholds to approximate the range of final 2024 IDR fees. These values represented the percentage of OON claims that would be financially viable candidates for IDR submission. RESULTS. Among 76,221,264 claims for hospital-based specialties associated with in-network ED visits or inpatient stays, 1,482,973 (1.9%) were OON. The maximum potential payment exceeded fee thresholds of US$150 and US$450 for 55.0% and 32.1%, respectively, of batched OON claims for radiologists and 76.8% and 61.3% of batched OON claims for all other hospital-based specialties combined. At payment of one-quarter of that amount, these values were 26.9% and 10.6%, respectively, for radiologists and 56.6% and 38.4% for all other hospital-based specialties combined. CONCLUSION. The IDR process would be financially unviable for a substantial fraction of OON claims for hospital-based specialists (more so for radiology than for other such specialties). CLINICAL IMPACT. Although the NSA enacted important patient protections, IDR fees limit clinicians' opportunities to dispute payer-determined payments and potentially undermine their bargaining power in contract negotiations. Therefore, IDR rulemaking may negatively impact patient access to in-network care.

The impact of surprise billing laws on emergency services.

Numerous states implemented laws to protect emergency patients from surprise out-of-network medical bills. We investigated the effects of the state laws on emergency clinician reimbursements, charges, network participation, and potential surprise billing episodes. We did not find consistent evidence of effects on prices or charges. However, the state laws resulted in increased network participation and a reduction in potential surprise billing episodes. Our results suggest that the federal No Surprises Act, which is similar to many of the state laws, is unlikely to lead to price increases, but may benefit patients through increased provider network participation and alignment.

Refractive outcomes using Barrett formulas and patient characteristics of cataract surgery patients with and without prior LASIK/PRK.

PURPOSE: The goal of this study is to describe characteristics of cataract surgery patients who previously underwent laser in situ keratomileusis/photorefractive keratectomy (LASIK/PRK) in comparison to non-LASIK/PRK cataract surgery patients including psychiatric comorbidities, as well as describe refractive prediction error after cataract surgery while accounting for axial length (AL) using the Barrett True-K and Barrett Universal II formulas. METHODS: This was a retrospective study of patients from the University of Colorado Cataract Outcomes Registry. The primary outcomes were refraction prediction error (RPE), mean absolute RPE, and median absolute RPE. Outcomes were stratified by five axial length groups. Univariate and multivariate models for RPE were stratified by the AL group. RESULTS: Two hundred eighty-one eyes with prior LASIK/PRK and 3101 eyes without are included in the study. Patients with prior LASIK/PRK were significantly younger: 67.0 vs 69.9 years, p < 0.0001. The LASIK/PRK group had significantly better mean pre-operative BCVA in comparison to the non-LASIK group, logMAR 0.204 vs logMAR 0.288, p = 0.003. The LASIK/PRK group had significantly lower rates of cardiovascular disease (18.5% vs 29.3%, p < 0.001), hypertension (49.1% vs 59.3%, p < 0.012), and type 2 diabetes (10.7% vs 26.0%, p < 0.001), and no significant difference in psychiatric disease. The absolute RPE was higher for the LASIK group for all ALs, but only significantly higher for eyes with AL less than 25 mm. CONCLUSION: Patient eyes with prior LASIK/PRK surgery undergoing cataract surgery were significantly younger, had significantly less comorbidities, and a significantly better pre-operative BCVA. Using the Barrett formulas, absolute prediction error for eyes with longer ALs was not significantly worse for LASIK/PRK eyes than those without and the difference was smaller for eyes with longer AL.

Stable individual differences in infants' responses to violations of intuitive physics.

Infants look longer at impossible or unlikely events than at possible events. While these responses to expectancy violations have been critical for understanding early cognition, interpreting them is challenging because infants' responses are highly variable. This variability has been treated as an unavoidable nuisance inherent to infant research. Here we asked whether the variability contains signal in addition to noise: namely, whether some infants show consistently stronger responses to expectancy violations than others. Infants watched two unrelated physical events 6 mo apart; these events culminated in either an impossible or an expected outcome. We found that infants who exhibited the strongest looking response to an impossible event at 11 mo also exhibited the strongest response to an entirely different impossible event at 17 mo. Furthermore, violation-of-expectation responses in infancy predicted children's explanation-based curiosity at 3 y old. In contrast, there was no longitudinal relation between infants' responses to events with expected outcomes at 11 and 17 mo, nor any link with later curiosity; hence, infants' responses do not merely reflect individual differences in attention but are specific to expectancy violations. Some children are better than others at detecting prediction errors-a trait that may be linked to later cognitive abilities.

The utility of the surprise question by nurses to identify hospitalised older patients nearing the end-of-life and promotion of advance care planning: An interventional study.

AIMS AND OBJECTIVES: To assess the prognostic accuracy of the surprise question (SQ) when used by nurses working in hospital wards to determine 1-year mortality in acutely hospitalised older patients. BACKGROUND: The predictive accuracy of the SQ, when used by general nurses caring for older hospitalised patients, has not been comprehensively studied. DESIGN: A prospective cohort study. METHODS: This cohort study recruited consecutive 10,139 older patients (aged ≥65 years) who were admitted to Taipei City Hospital and were evaluated for the needs of palliative care in 2015. All patients were followed up for 12 months or until their death. The c-statistic value was calculated to indicate the predictive accuracy of the SQ and Palliative Care Screening Tool (PCST). RESULTS: Of all participants, 18.8% and 18.6% had a SQ response of 'no' and a PCST score ≥4, respectively. After controlling for other covariates, an SQ response of 'no' (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.83-2.31) and a PCST score ≥4 (AHR = 1.50; 95% CI: 1.29-1.75) were found to be the independent predictors for patients' 12-month mortality. The C-statistic values of the SQ and the PCST at recognising patients in their last year of life were .663 and .670, respectively. Moreover, there was moderate concordance (k = .44) between the SQ and the PCST in predicting 12-month mortality. CONCLUSIONS: SQ response of 'no' and a PCST score ≥4 were independent predictors of 12-month mortality in older patients. RELEVANCE TO CLINICAL PRACTICE: The SQ, when used by nurses working in hospital wards, is effective in identifying older patients nearing the end of life, as well as in providing advance care planning for patients. PATIENT OR PUBLIC CONTRIBUTION: Patients' palliative care needs at admission were assessed by general nurses using the SQ and PCST.

Experiencing Surprise: The Temporal Dynamics of Its Impact on Memory.

To efficiently process information, the brain shifts between encoding and retrieval states, prioritizing bottom-up or top-down processing accordingly. Expectation violation before or during learning has been shown to trigger an adaptive encoding mechanism, resulting in better memory for unexpected events. Using fMRI, we explored (1) whether this encoding mechanism is also triggered during retrieval, and if so, (2) what the temporal dynamics of its mnemonic consequences are. Male and female participants studied object images, then, with new objects, they learned a contingency between a cue and a semantic category. Rule-abiding (expected) and violating (unexpected) targets and similar foils were used at test. We found interactions between previous and current similar events' expectation, such that when an expected event followed a similar but unexpected event, its performance was boosted, underpinned by activation in the hippocampus, midbrain, and occipital cortex. In contrast, a sequence of two unexpected similar events also triggered occipital engagement; however, this did not enhance memory performance. Taken together, our findings suggest that when the goal is to retrieve, encountering surprising events engages an encoding mechanism, supported by bottom-up processing, that may enhance memory for future related events.SIGNIFICANCE STATEMENT Optimizing the balance between new learning and the retrieval of existing knowledge is an ongoing process, at the core of human cognition. Previous research into memory encoding suggests experiencing surprise leads to the prioritization of the learning of new memories, forming an adaptive encoding mechanism. We examined whether this mechanism is also engaged when the current goal is to retrieve information. Our results demonstrate that an expectation-driven shift toward an encoding state, supported by enhanced perceptual processing, is beneficial for the correct identification of subsequent expected similar events. These findings have important implications for our understanding of the temporal dynamics of the adaptive encoding of information into memory.

Stimulus expectations do not modulate visual event-related potentials in probabilistic cueing designs.

Humans and other animals can learn and exploit repeating patterns that occur within their environments. These learned patterns can be used to form expectations about future sensory events. Several influential predictive coding models have been proposed to explain how learned expectations influence the activity of stimulus-selective neurons in the visual system. These models specify reductions in neural response measures when expectations are fulfilled (termed expectation suppression) and increases following surprising sensory events. However, there is currently scant evidence for expectation suppression in the visual system when confounding factors are taken into account. Effects of surprise have been observed in blood oxygen level dependent (BOLD) signals, but not when using electrophysiological measures. To provide a strong test for expectation suppression and surprise effects we performed a predictive cueing experiment while recording electroencephalographic (EEG) data. Participants (n=48) learned cue-face associations during a training session and were then exposed to these cue-face pairs in a subsequent experiment. Using univariate analyses of face-evoked event-related potentials (ERPs) we did not observe any differences across expected (90% probability), neutral (50%) and surprising (10%) face conditions. Across these comparisons, Bayes factors consistently favoured the null hypothesis throughout the time-course of the stimulus-evoked response. When using multivariate pattern analysis we did not observe above-chance classification of expected and surprising face-evoked ERPs. By contrast, we found robust within- and across-trial stimulus repetition effects. Our findings do not support predictive coding-based accounts that specify reduced prediction error signalling when perceptual expectations are fulfilled. They instead highlight the utility of other types of predictive processing models that describe expectation-related phenomena in the visual system without recourse to prediction error signalling.

EEG mismatch responses in a multimodal roving stimulus paradigm provide evidence for probabilistic inference across audition, somatosensation, and vision.

The human brain is constantly subjected to a multimodal stream of probabilistic sensory inputs. Electroencephalography (EEG) signatures, such as the mismatch negativity (MMN) and the P3, can give valuable insight into neuronal probabilistic inference. Although reported for different modalities, mismatch responses have largely been studied in isolation, with a strong focus on the auditory MMN. To investigate the extent to which early and late mismatch responses across modalities represent comparable signatures of uni- and cross-modal probabilistic inference in the hierarchically structured cortex, we recorded EEG from 32 participants undergoing a novel tri-modal roving stimulus paradigm. The employed sequences consisted of high and low intensity stimuli in the auditory, somatosensory and visual modalities and were governed by unimodal transition probabilities and cross-modal conditional dependencies. We found modality specific signatures of MMN (~100-200 ms) in all three modalities, which were source localized to the respective sensory cortices and shared right lateralized prefrontal sources. Additionally, we identified a cross-modal signature of mismatch processing in the P3a time range (~300-350 ms), for which a common network with frontal dominance was found. Across modalities, the mismatch responses showed highly comparable parametric effects of stimulus train length, which were driven by standard and deviant response modulations in opposite directions. Strikingly, P3a responses across modalities were increased for mispredicted stimuli with low cross-modal conditional probability, suggesting sensitivity to multimodal (global) predictive sequence properties. Finally, model comparisons indicated that the observed single trial dynamics were best captured by Bayesian learning models tracking unimodal stimulus transitions as well as cross-modal conditional dependencies.

Variability in Excess Lobectomy Billing Among US Thoracic Surgeons.

BACKGROUND: Transparency in physician billing practices in the United States is lacking. Often, charges may vary substantially between providers and excess charges may be passed on to the patient. In this study, we evaluate Medicare charges and payments for minimally invasive lobectomy to obtain a sense of national billing practices and evaluate for predictors of higher charges. METHODS: The 2018 Medicare Provider Utilization Data was queried to identify surgeons submitting charges for Video-Assisted Thoracoscopic Lobectomy. Excess charges were determined by each provider. Additional demographic variables were collected including geographic region for general surgery and cardiothoracic surgery training, years in practice, and current practice setting. A multivariate gamma regression was utilized to determine predictors of high billing practices. RESULTS: A total of 307 unique providers submitted charges ranging from $1,104 to $25,128 with a median of $4,265. The average Medicare Payment amount ranged from $163 to $1,409, with a median of $1,056. Male surgeons were estimated to charge 1.3 times more than female surgeons, while those in an academic setting were estimated to charge 1.4 times more than private practice (p < 0.01). Surgeons practicing in the South or West were estimated to charge 0.76 and 0.81 times as much as those practicing in the Northeast (p < 0.01). CONCLUSIONS: Billing practices vary widely across the United States. Charges submitted to Medicare likely represent a provider's charges across all payers. In today's healthcare economy, it is important for patients to understand the true cost of care and for providers to be mindful of reasonable and appropriate charges.

How infant-directed actions enhance infants' attention, learning, and exploration: Evidence from EEG and computational modeling.

When teaching infants new actions, parents tend to modify their movements. Infants prefer these infant-directed actions (IDAs) over adult-directed actions and learn well from them. Yet, it remains unclear how parents' action modulations capture infants' attention. Typically, making movements larger than usual is thought to draw attention. Recent findings, however, suggest that parents might exploit movement variability to highlight actions. We hypothesized that variability in movement amplitude rather than higher amplitude is capturing infants' attention during IDAs. Using EEG, we measured 15-month-olds' brain activity while they were observing action demonstrations with normal, high, or variable amplitude movements. Infants' theta power (4-5 Hz) in fronto-central channels was compared between conditions. Frontal theta was significantly higher, indicating stronger attentional engagement, in the variable compared to the other conditions. Computational modelling showed that infants' frontal theta power was predicted best by how surprising each movement was. Thus, surprise induced by variability in movements rather than large movements alone engages infants' attention during IDAs. Infants with higher theta power for variable movements were more likely to perform actions successfully and to explore objects novel in the context of the given goal. This highlights the brain mechanisms by which IDAs enhance infants' attention, learning, and exploration.

Brain Responses to Surprising Stimulus Offsets: Phenomenology and Functional Significance.

Abrupt increases of sensory input (onsets) likely reflect the occurrence of novel events or objects in the environment, potentially requiring immediate behavioral responses. Accordingly, onsets elicit a transient and widespread modulation of ongoing electrocortical activity: the Vertex Potential (VP), which is likely related to the optimisation of rapid behavioral responses. In contrast, the functional significance of the brain response elicited by abrupt decreases of sensory input (offsets) is more elusive, and a detailed comparison of onset and offset VPs is lacking. In four experiments conducted on 44 humans, we observed that onset and offset VPs share several phenomenological and functional properties: they (1) have highly similar scalp topographies across time, (2) are both largely comprised of supramodal neural activity, (3) are both highly sensitive to surprise and (4) co-occur with similar modulations of ongoing motor output. These results demonstrate that the onset and offset VPs largely reflect the activity of a common supramodal brain network, likely consequent to the activation of the extralemniscal sensory system which runs in parallel with core sensory pathways. The transient activation of this system has clear implications in optimizing the behavioral responses to surprising environmental changes.

A comparison of palliative care and rapid emergency screening (P-CaRES) tool, broad and narrow criteria, and surprise questions to predict survival of older emergency department patients.

BACKGROUND: Palliative care is a form of medical care designed to enhance the quality of life of patients with life-threatening conditions. This study was conducted to compare the accuracy of predicted survival the 1 and 3-month survival rate of Broad and narrow criteria, Surprise questions (SQ), and Palliative Care and Rapid Emergency Screening (P-CaRES) after admission to the emergency department (ED). METHODS: This prospective cohort study was conducted at an urban teaching hospital in Thailand. Patients aged ≥ 65 years admitted to the ED were classified according to their emergency severity index (ESI) (Level: 1-3). We collected data on SQ, P-CaRES, and broad and narrow criteria. A survival data of participants were collected at 1 and 3 months after admission to the ED. The survival rate was calculated using the Kaplan-Meier and log-rank tests. RESULTS: A total of 269 patients completed the study. P-CaRES positive and P-CaRES negative patients had 1-month survival rates of 81% and 94.8%, respectively (P = 0.37), and at 3-month survival rates of 70.7% and 90.1%, respectively (P < 0.001). SQ (not surprised) had a 1-month survival rate of 79.3%, while SQ (surprised) had a 97% survival rate (P = 0.01), and SQ (not surprised) had a 75.4% survival rate at 3-months, while SQ (surprised) had a 96.3% survival rate (P = 0.01). Broad and narrow criteria that were positive and negative had 1-month survival rates of 88.1% and 92.5%, respectively (P = 0.71), while those that were positive and negative had 3-month survival rates of 78.6% and 87.2%, respectively (P = 0.19). The hazard ratio (HR) of SQ (not surprised) at 1 month was 3.22( 95%CI:1.16-8.89). The HR at 3 months of P-CaRES (positive) was 3.31 with a 95% confidence interval (CI): 1.74 - 6.27, while the HR for SQ (not surprise) was 7.33, 95% CI: 3.03-19.79; however, broad and narrow criteria had an HR of 1.78, 95% CI:0.84-3.77. CONCLUSIONS: Among older adults who visited the ED, the SQ were good prognosis tools for predicting 1 and 3-month survival, and P-CaRES were good prognostic tools for predicting 3-month survival.

Early warning systems and end-user decision-making: A risk formalism tool to aid communication and understanding.

In this work, we introduce a formalism to highlight the role of decision-making implicit in the setup of early warning systems (EWSs) and its consequences with respect to loss avoidance for end users. The formalism, a close relative of the cost/loss approach, combines EWS verification scores with traditional expressions of risk from the point of view of the user. This formalism articulates in mathematical format many well-known issues surrounding EWS usage, offering a conceptual anchor for concepts that otherwise may seem to wobble among the multidisciplinary perspectives participating in the EWS chain. This decision model is visually represented in a variation of the popular "performance diagram" used in forecast and warning verification. Our diagram adds to this the perspective of a generic user, in an effort to gain insight into how choices made regarding EWS settings may determine which users benefit from warnings and which do not. Although these results are based on a conceptual model, they are useful to better understand the actual benefits experienced by users and to highlight aspects that may temper unrealistic expectations on EWSs. The recent United Nations initiative to extend EWSs for natural hazards to all nations within 5 years will make EWSs more common and more public. The approach proposed here can be a tool to promote greater transparency and improve the necessary dialog between warning issuers and users in order to reduce loss.

The applicability of the "surprise question" as a prognostic tool in patients with severe chronic comorbidities in a university teaching outpatient setting.

BACKGROUND: Life expectancy in recent decades has increased the prevalence of chronic diseases in the population, requiring an approach to new health topics, such as discussions on quality of life and expectations about death and dying. The concept of advance directives (ADs) gives individuals the opportunity to make known their decisions about the treatments they would like to receive at the end of life. Despite the recognition of relevance in clinical practice, the applicability of the concept presents challenges, including establishing the appropriate prognosis for each patient and the ideal time to approach the patient. Some prognostic tools were developed, such as the surprise question (SQ): "Would you be surprised if your patient died in 12 months?", which is used in some clinical settings to predict patient deaths and to make decisions regarding ADs. The main objective of the present study was to evaluate the behavior of second-year resident physicians (PGY-2) when the SQ was applied. METHOD: In our observational study, from July 1, 2016, to February 28, 2017, (PGY-2) in the Internal Medicine Residency Program (IMRP) applied SQ to all patients with multiple and varied chronic no communicable comorbidities, who were followed up at the general medicine outpatient clinic (GMOC) of a tertiary university hospital in São Paulo- Brazil. The frequency of the outcome (death or non-death within 12 months) was analyzed by correlating it with the clinical data (impact of the studied variables). RESULTS: Eight hundred forty patients entered the study. Fitfty-two of them (6.2%) died within one year. PGY-2 predicted that two hundred and fourteen patients (25.5% of total) would die within a year (answer No to SQ), of which, 32 (14.9%) did so. The correct residents' prognosis for the subgroup of 626 patients (answer "Yes" to SQ) was NPV = 96.8% (CI = 95.4%-98.2%) and PPV = 14.9% (CI 10.1%-19, 6%). Answering "Yes" to SQ correlated negatively to addressing AD while the outcomes death and the answer No to SQ were positively correlated, according to the number of comorbidities. CONCLUSION: The SQ, in addition to care, contributed to health education, communication and care planning shared by the doctor and patient.

Mark-Up Trends in Contemporary Medicare Primary and Revision Total Joint Arthroplasty.

BACKGROUND: Understanding mark-up ratios (MRs), the ratio between a healthcare institution's submitted charge and the Medicare payment received, for high-volume orthopaedic procedures is imperative to inform policy about price transparency and reducing surprise billing. This analysis examined the MRs for primary and revision total hip and knee arthroplasty (THA and TKA) services to Medicare beneficiaries between 2013 and 2019 across healthcare settings and geographic regions. METHODS: A large dataset was queried for all THA and TKA procedures performed by orthopaedic surgeons between 2013 and 2019, using Healthcare Common Procedure Coding System (HCPCS) codes for the most frequently used services. Yearly MRs, service counts, average submitted charges, average allowed payments, and average Medicare payments were analyzed. Trends in MRs were assessed. We evaluated 9 THA HCPCS codes, averaging 159,297 procedures a year provided by a mean of 5,330 surgeons. We evaluated 6 TKA HCPCS codes, averaging 290,244 procedures a year provided by a mean of 7,308 surgeons. RESULTS: For knee arthroplasty procedures, a decrease was noted for HCPCS code 27438 (patellar arthroplasty with prosthesis) over the study period (8.30 to 6.62; P = .016) and HCPCS code 27447 (TKA) had the highest median (interquartile range [IQR]) MR (4.73 [3.64 to 6.30]). For revision knee procedures, the highest median (IQR) MR was for HCPCS code 27488 (removal of knee prosthesis; 6.12 [3.83-8.22]). While no trends were noted for both primary and revision hip arthroplasty, median (IQR) MRs in 2019 for primary hip procedures ranged from 3.83 (hemiarthroplasty) to 5.06 (conversion of previous hip surgery to THA) and HCPCS code 27130 (total hip arthroplasty) had a median (IQR) MR of 4.66 (3.58-6.44). For revision hip procedures, MRs ranged from 3.79 (open treatment of femoral fracture or prosthetic arthroplasty) to 6.10 (revision of THA femoral component). Wisconsin had the highest median MR by state (>9) for primary knee, revision knee, and primary hip procedures. CONCLUSION: The MRs for primary and revision THA and TKA procedures were strikingly high, as compared to nonorthopaedic procedures. These findings represent high levels of excess charges billed, which may pose serious financial burdens to patients and must be taken into consideration in future policy discussions to avoid price inflation.

Variation in Public Support for Government Action on Unexpected Medical Bills.

CONTEXT: Nearly half of the adults in the United States have received an unexpected medical bill in recent years. While government, provider, and insurance policies related to unexpected medical expenses receive attention in the media, this study focuses on variation in public support. METHODS: The study employs two multifactor survey vignette experiments to detect how different features of common health care scenarios that result in costly medical expenses influence the public's sympathy for the patient, perceived fairness of the medical costs, and demand for government action. FINDINGS: The results point to out-of-pocket cost, severity of the treatment, and the patient's insurance situation as important for public opinion. The public is significantly more supportive of government action when the costs are high and out of the patient's control; in contrast, respondents are generally less sympathetic toward patients described as uninsured or who seek out more costly providers. CONCLUSIONS: The findings underscore the sensitivity of health care attitudes to framing effects, which may occur when media choose how to cover health care costs. The results also point to a potential mismatch in legislation that narrowly addresses "surprise billing," with public support for government addressing disproportionate costs across a broader range of scenarios.