Alternative Payment Models and Working with Payers-Key Considerations for Advancing Population Health Goals and Achieving Child Health Equity.

This article summarizes approaches to achieving value-based care in Pediatrics, providing a framework for understanding the continuum of models from fee-for-service to advanced alternative payment models. We present key examples of how alternative payment models have been developed and applied at the federal level within Medicare through the work of the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicaid and Medicaid Innovation (CMMI). We further describe key lessons learned and opportunities to adapt value-based payment models to promote whole child health and equity. Finally, we summarize policy considerations and challenges in achieving accountability and aligning financial incentives for children's health within a complex payer landscape.

Reproductive inequality in humans and other mammals.

To address claims of human exceptionalism, we determine where humans fit within the greater mammalian distribution of reproductive inequality. We show that humans exhibit lower reproductive skew (i.e., inequality in the number of surviving offspring) among males and smaller sex differences in reproductive skew than most other mammals, while nevertheless falling within the mammalian range. Additionally, female reproductive skew is higher in polygynous human populations than in polygynous nonhumans mammals on average. This patterning of skew can be attributed in part to the prevalence of monogamy in humans compared to the predominance of polygyny in nonhuman mammals, to the limited degree of polygyny in the human societies that practice it, and to the importance of unequally held rival resources to women's fitness. The muted reproductive inequality observed in humans appears to be linked to several unusual characteristics of our species-including high levels of cooperation among males, high dependence on unequally held rival resources, complementarities between maternal and paternal investment, as well as social and legal institutions that enforce monogamous norms.

Characterizing Veterans Crisis Line callers and regional follow-up efforts.

The Veterans Crisis Line (VCL) is a national resource offering Veterans 24/7 access to crisis responders and follow-up by a licensed mental health clinician at a Veterans Affairs medical center. This quality improvement project aimed to improve local suicide prevention efforts at the VA Puget Sound Health Care System by characterizing 344 VCL calls and outcomes. Data was extracted from documentation by national VCL responders and local Suicide Prevention Team members. Overall, most callers were assessed at low-to-moderate risk. VCL responders were more likely to assess callers reporting suicidal ideation (SI) as high-risk, but less likely to assess those reporting financial issues as high-risk. VCL calls about SI, about physical health, or that occurred on weekends were more likely to end with immediate evaluation (i.e., emergency room, evaluated by first-responders) compared to their respective comparison groups. VCL calls assessed as high-risk were more likely to report SI during local follow-up contact, whereas VCL calls ending in immediate evaluation (i.e., emergency room, evaluated by first-responders) were less likely to report SI during follow-up with the local VA clinician; 17% of VCL calls without SI reported SI at follow-up. Training of local Suicide Prevention Team members should include that SI can change rapidly and requires assessment regardless of SI during the VCL call.

What is "safety"?: Lethal means counseling as a cross-cultural communication.

U.S. suicide rates have risen every year over the past two decades with self-directed firearm use as the method accounting for the highest proportion of deaths. This pattern is particularly pronounced among veterans and members of the U.S. Armed Forces. The numerical burden of firearm-related suicide accompanied by characteristics of self-directed firearm injury have motivated the development of lethal means safety initiatives focused on firearms. Simultaneously, research has sought to characterize patterns of firearm ownership and use among veterans as well as optimal strategies for clinicians to deliver suicide prevention messages to firearm owners. Increasingly, findings from research have been understood as cultural factors that warrant greater attention to improve the quality of lethal means counseling. Here, we review and interpret selected research on cultural aspects of firearm ownership and suggest that cultural differences between health care practitioners and firearm owners may result in health care practitioners delivering clinical interventions that are broadly divergent from perspectives within the cultural frameworks of firearm owners. We follow by organizing these cultural factors into existing frameworks of cultural competency training as a basis for developing curriculum for health care practitioners to improve clinical care.

Evolution of water conservation in humans.

To sustain life, humans and other terrestrial animals must maintain a tight balance of water gain and water loss each day.1-3 However, the evolution of human water balance physiology is poorly understood due to the absence of comparative measures from other hominoids. While humans drink daily to maintain water balance, rainforest-living great apes typically obtain adequate water from their food and can go days or weeks without drinking4-6. Here, we compare isotope-depletion measures of water turnover (L/d) in zoo- and rainforest-sanctuary-housed apes (chimpanzees, bonobos, gorillas, and orangutans) with 5 diverse human populations, including a hunter-gatherer community in a semi-arid savannah. Across the entire sample, water turnover was strongly related to total energy expenditure (TEE, kcal/d), physical activity, climate (ambient temperature and humidity), and fat free mass. In analyses controlling for those factors, water turnover was 30% to 50% lower in humans than in other apes despite humans' greater sweating capacity. Water turnover in zoo and sanctuary apes was similar to estimated turnover in wild populations, as was the ratio of water intake to dietary energy intake (∼2.8 mL/kcal). However, zoo and sanctuary apes ingested a greater ratio of water to dry matter of food, which might contribute to digestive problems in captivity. Compared to apes, humans appear to target a lower ratio of water/energy intake (∼1.5 mL/kcal). Water stress due to changes in climate, diet, and behavior apparently led to previously unknown water conservation adaptations in hominin physiology.

Assessing conservation attitudes and behaviors of Congolese children neighboring the world's first bonobo (Pan paniscus) release site.

Poaching and habitat destruction in the Congo Basin threaten African great apes including the bonobo (Pan paniscus), chimpanzees (Pan troglodytes), and gorillas (Gorilla spp.) with extinction. One way to combat extinction is to reintroduce rescued and rehabilitated apes and repopulate native habitats. Reintroduction programs are only successful if they are supported by local populations. Ekolo ya Bonobo, located in Equateur province of the Democratic Republic of Congo (DRC), is the world's only reintroduction site for rehabilitated bonobos. Here we assess whether children, of the Ilonga-Pôo, living adjacent to Ekolo ya Bonobo demonstrate more pro-ape conservation attitudes than children living in, Kinshasa, the capital city. We examined children's attitudes toward great apes because children are typically the focus of conservation education programs. We used the Great Ape Attitude Questionnaire to test the Contact Hypothesis, which posits that proximity to great ape habitat influences pro-conservation attitudes toward great apes. Ilonga-Pôo children who live in closer contact with wild bonobos felt greater responsibility to protect great apes compared to those in Kinshasa who live outside the natural habitat of great apes. These results suggest that among participants in the DRC, spatial proximity to a species fosters a greater sense of responsibility to protect and conserve. These results have implications for the successful implementation of great ape reintroduction programs in the Congo Basin. The data analyzed in this study were collected in 2010 and therefore provide a baseline for longitudinal study of this reintroduction site.

Three Strategies to Overcome Data-Sharing Challenges to Improve the Social Determinants of Health.

This piece identifies and compares three examples of successful data sharing that sought to improve housing and health outcomes, ultimately improving the lives of vulnerable groups. Data strategists should first consider proving out the benefit in consultation with diverse stakeholders, mitigating legal risks from the beginning, and starting with a minimal data prototype.

Sexual dimorphism in chimpanzee (Pan troglodytes schweinfurthii) and human age-specific fertility.

Across vertebrates, species with intense male mating competition and high levels of sexual dimorphism in body size generally exhibit dimorphism in age-specific fertility. Compared with females, males show later ages at first reproduction and earlier reproductive senescence because they take longer to attain adult body size and musculature, and maintain peak condition for a limited time. This normally yields a shorter male duration of effective breeding, but this reduction might be attenuated in species that frequently use coalitionary aggression. Here, we present comparative genetic and demographic data on chimpanzees from three long-term study communities (Kanyawara: Kibale National Park, Uganda; Mitumba and Kasekela: Gombe National Park, Tanzania), comprising 581 male risk years and 112 infants, to characterize male age-specific fertility. For comparison, we update estimates from female chimpanzees in the same sites and append a sample of human foragers (the Tanzanian Hadza). Consistent with the idea that aggressive mating competition favors youth, chimpanzee males attained a higher maximum fertility than females, followed by a steeper decline with age. Males did not show a delay in reproduction compared with females, however, as adolescents in both sites successfully reproduced by targeting young, subfecund females, who were less attractive to adults. Gombe males showed earlier reproductive senescence and a shorter duration of effective breeding than Gombe females. By contrast, older males in Kanyawara generally continued to reproduce, apparently by forming coalitions with the alpha. Hadza foragers showed a distinct pattern of sexual dimorphism in age-specific fertility as, compared with women, men gained conceptions later but continued reproducing longer. In sum, both humans and chimpanzees showed sexual dimorphism in age-specific fertility that deviated from predictions drawn from primates with more extreme body size dimorphism, suggesting altered dynamics of male-male competition in the two lineages. In both species, coalitions appear important for extending male reproductive careers.

Inbreeding risk and maternal support have opposite effects on female chimpanzee dispersal.

Sex-biased dispersal is usually driven by a combination of inbreeding avoidance and intrasexual competition. Walker and Pusey show that dispersal decisions in chimpanzees are most influenced by inbreeding avoidance and kin cooperation, instead of competition.

Males with a mother living in their group have higher paternity success in bonobos but not chimpanzees.

In many group-living mammals, mothers may increase the reproductive success of their daughters even after they are nutritionally independent and fully grown [1]. However, whether such maternal effects exist for adult sons is largely unknown. Here we show that males have higher paternity success when their mother is living in the group at the time of the offspring's conception in bonobos (N = 39 paternities from 4 groups) but not in chimpanzees (N = 263 paternities from 7 groups). These results are consistent with previous research showing a stronger role of mothers (and females more generally) in bonobo than chimpanzee societies.

The Wood-Ljungdahl pathway as a key component of metabolic versatility in candidate phylum Bipolaricaulota (Acetothermia, OP1).

The Wood-Ljungdahl (WL) pathway is an important component of the metabolic machinery in multiple anaerobic prokaryotes, including numerous yet-uncultured bacterial phyla. The pathway can operate in the reductive and oxidative directions, enabling a wide range of metabolic processes. Here, we present a detailed analysis of 14 newly acquired, previously analysed, and publicly available genomic assemblies belonging to the candidate phylum Bipolaricaulota (candidate division OP1, and candidatus Acetothermia), where the occurrence of WL pathway appears to be universal. In silico analysis of predicted metabolic capabilities indicates that the pathway enables homoacetogenic fermentation of sugars and amino acids in all three Bipolaricaulota orders (RBG-16-55-9, UBA7950 and Bipolaricaulales). In addition, members of RBG-16-55-9 appear to possess the additional capacity for syntrophic acetate oxidation using the WL pathway; as well as for respiratory growth using oxygen or nitrate. Anabolically, all UBA7950, and the majority of the Bipolaricaulales genomes possess the capacity for autotrophic growth using the WL pathway. Our results highlight the WL-enabled metabolic versatility in the Bipolaricaulota, emphasize the need for examining the WL pathway in context of the overall metabolic circuitry in uncultured taxa, and demonstrate the value of comparative genomic analysis for providing a detailed overview of metabolic potential in a target microbial lineage and its potential functional niche in an ecosystem.