The impact of urbanization on health depends on the health metric, life stage and level of urbanization: a global meta-analysis on avian species.

Stressors associated with urban habitats have been linked to poor wildlife health but whether a general negative relationship between urbanization and animal health can be affirmed is unclear. We conducted a meta-analysis of avian literature to test whether health biomarkers differed on average between urban and non-urban environments, and whether there are systematic differences across species, biomarkers, life stages and species traits. Our dataset included 644 effect sizes derived from 112 articles published between 1989 and 2022, on 51 bird species. First, we showed that there was no clear impact of urbanization on health when we categorized the sampling locations as urban or non-urban. However, we did find a small negative effect of urbanization on health when this dichotomous variable was replaced by a quantitative variable representing the degree of urbanization at each location. Second, we showed that the effect of urbanization on avian health was dependent on the type of health biomarker measured as well as the individual life stage, with young individuals being more negatively affected. Our comprehensive analysis calls for future studies to disentangle specific urban-related drivers of health that might be obscured in categorical urban versus non-urban comparisons.

Ancient herders enriched and restructured African grasslands.

Grasslands are one of the world's most extensive terrestrial biomes and are central to the survival of herders, their livestock and diverse communities of large wild mammals1-3. In Africa, tropical soils are predominantly nutrient-limited4-6 but productive grassy patches in wooded grassland savannah ecosystems2,4 grow on fertile soils created by geologic and edaphic factors, megafauna, fire and termites4-6. Mobile pastoralists also create soil-fertility hotspots by penning their herds at night, which concentrates excrement-and thus nutrients-from grazing of the surrounding savannahs7-11. Historical anthropogenic hotspots produce high-quality forage, attract wildlife and increase spatial heterogeneity in African savannahs4,12-15. Archaeological research suggests this effect extends back at least 1,000 years16-19 but little is known about nutrient persistence at millennial scales. Here we use chemical, isotopic and sedimentary analyses to show high nutrient and 15N enrichment in on-site degraded dung deposits relative to off-site soils at five Pastoral Neolithic20 sites (radiocarbon dated to between 3,700 and 1,550 calibrated years before present (cal. BP)). This study demonstrates the longevity of nutrient hotspots and the long-term legacy of ancient herders, whose settlements enriched and diversified African savannah landscapes over three millennia.

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021.

Importance: Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. Objective: To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. Design, Setting, and Participants: In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Exposures: Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Main Outcomes and Measures: Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. Results: More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Conclusions and Relevance: Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

Occupational survey of airborne metal exposures to welders, metalworkers, and bystanders in small fabrication shops.

The objective of this study was to characterize worker exposure to airborne metal and particulate matter in shops where multiple types of metalworking tasks were performed. The sampling strategy included full-shift and task-based personal samples on workers who performed flux-cored arc welding, personal samples on workers performing non-welding metalworking tasks, and area samples near welders, representing bystanders to welding. Size-fractionated particulate matter adjacent to welding activities was measured using real-time monitoring devices. Samples were analyzed for 21 individual metals, of which 8 were frequently detected. Exceedance fractions were calculated based on the distribution of results for each frequently detected metal. Exceedance fractions were <5% for all metals, except manganese (6% of the REL, 55% of the inhalable TLV-TWA and 91% of the respirable TLV-TWA) and iron oxide (10% of the REL and TLV-TWA) for Shop 1 bystander samples, manganese (68% for the inhalable TLV-TWA and 98% of the respirable TLV-TWA) for welder samples, and manganese (35% for the inhalable TLV-TWA and 80% of the respirable TLV-TWA) and iron oxide (12% for the PEL and 23% for the REL and TLV-TWA) for metalworker samples. Particulate matter concentrations measured at distances of 0.9-1.5 m and 2.1-2.7 m from the welder were within the same order of magnitude. The results of this study allow for comparison to health-based exposure limits for select individual components of welding fume with a low to medium degree of censorship.

Carbon and nitrogen isotope variability in the seeds of two African millet species: Pennisetum glaucum and Eleusine coracana.

RATIONALE: A range of important small seeded C4 crops were domesticated in Africa, but little is known about their carbon and nitrogen isotope ratios (δ13 C and δ15 N values). Understanding natural isotopic variability within and among millets has the potential to help us to understand the conditions under which ancient cereals were grown and has significant implications for the interpretation of ancient diets based on stable isotope signatures. METHODS: We conducted carbon and nitrogen isotope analyses of modern and historical pearl millet (Pennisetum glaucum, n = 108) and finger millet (Eleusine coracana, n = 17) seed samples sourced from the United States Department of Agriculture as well as the Harlan Collection curated at the Crop Evolution Laboratory Herbarium at the University of Illinois. RESULTS: The millet species have significantly different mean carbon and nitrogen isotope ratios over broad temporal and spatial scales. We also found substantial isotopic variation within species (range of 1.9‰ and 8.5‰ in δ13 C and δ15 N values, respectively). Both water availability and growing season temperature significantly affected the P. glaucum δ13 C and δ15 N values; cumulative annual precipitation was positively correlated with both seed δ13 C and δ15 N values, while temperature was positively correlated with δ15 N values but negatively correlated with seed δ13 C values. CONCLUSIONS: The importance of both temperature and precipitation as predictors of δ13 C and δ15 N values in millets suggests that C4 plants may be more sensitive to environmental parameters than previously appreciated. Given the high degree of carbon and nitrogen isotope variability among accessions of these species, it is imperative that site-relevant plant isotope ratios are used for making isotope-based paleo-dietary predictions.

The Roles of Cost and Quality Information in Medicare Advantage Plan Enrollment Decisions: an Observational Study.

BACKGROUND: To facilitate informed decision-making in the Medicare Advantage marketplace, the Centers for Medicare & Medicaid Services publishes plan information on the Medicare Plan Finder website, including costs, benefits, and star ratings reflecting quality. Little is known about how beneficiaries weigh costs versus quality in enrollment decisions. OBJECTIVE: We aimed to assess associations between publicly reported Medicare Advantage plan attributes (i.e., costs, quality, and benefits) and brand market share and beneficiaries' enrollment decisions. DESIGN, SETTING, PARTICIPANTS: We performed a nationwide, beneficiary-level cross-sectional analysis of 847,069 beneficiaries enrolling in Medicare Advantage for the first time in 2011. MAIN MEASURES: Matching beneficiaries with their plan choice sets, we used conditional logistic regression to estimate associations between plan attributes and enrollment to assess the proportion of enrollment variation explained by plan attributes and willingness to pay for quality. KEY RESULTS: Relative to the total variation explained by the model, the variation in plan choice explained by premiums (25.7 %) and out-of-pocket costs (11.6 %) together explained nearly three times as much as quality ratings (13.6 %), but brand market share explained the most variation (35.3 %). Further, while beneficiaries were willing to pay more in total annual combined premiums and out-of-pocket costs for higher-rated plans (from $4,154.93 for 2.5-star plans to $5,698.66 for 5-star plans), increases in willingness to pay diminished at higher ratings, from $549.27 (95 %CI: $541.10, $557.44) for a rating increase from 2.5 to 3 stars to $68.22 (95 %CI: $61.44, $75.01) for an increase from 4.5 to 5 stars. Willingness to pay varied among subgroups: beneficiaries aged 64-65 years were more willing to pay for higher-rated plans, while black and rural beneficiaries were less willing to pay for higher-rated plans. CONCLUSIONS: While beneficiaries prefer higher-quality and lower-cost Medicare Advantage plans, marginal utility for quality diminishes at higher star ratings, and their decisions are strongly associated with plans' brand market share.

Recruitment difficulties in obstetric trials: a case study and review.

BACKGROUND: The CONSORT statement calls for complete data on flow of participants, including all losses and exclusions. Incomplete reporting of flow into trials versus flow through trials is not uncommon. Where complete data exist in obstetric trials, poor recruitment seems a recurring theme. AIMS: To explore difficulties in recruitment and differences between assessed-but-not-recruited and included women to improve future trial participation, using a case study of a recently published randomised trial of outpatient Foley catheter versus inpatient PGE2 gel for cervical ripening. MATERIALS & METHODS: The assessed-but-not-recruited population of an obstetric trial (ACTRN:12609000420246) was prospectively studied for reasons for noninclusion, demographic data and pregnancy outcome. Women assessed-but-not-recruited due to declined consent or obstetrician declined participation were compared to included women. Main outcome measures included demographic and outcome differences associated with trial participation. RESULTS: Of 468 assessed participants, 220 (47%) were not eligible by exclusion criteria (potential 'trial factor' recruitment difficulties), 147 (31%) declined consent (n = 100, 'participant factor') or their obstetrician declined participation (n = 47, 'clinician factor') and 101 (22%) were included. Declining women were more likely than participants to be parous (24 vs 10%, P < 0.05), induced for nonmedical reasons (18 vs 4%, P < 0.001), privately admitted (31 vs 3%, P < 0.001) and have longer inpatient stay (4.9 vs 4.2 days, P < 0.05). CONCLUSION: The high assessed-but-not-recruited rate highlights important issues with external validity and feasibility when conducting obstetric trials, including recruitment difficulties related to participant, clinician and trial factors. Assessed: recruited ratios and demographic and outcome differences need consideration in planning and interpretation of randomised trials.

Disproportionate mental health presentations to emergency departments in a coastal regional community in Australia of first nation people.

Emergency department (ED) presentations for mental health (MH) help-seeking have been rising rapidly in recent years. This research aims to identify the service usage demographic for people seeking MH care in the ED, specifically in this case, to understand the usage by First Nation people. This retrospective cohort study examined the sociodemographic and presentation characteristics of individuals seeking MH care in two EDs between 2016 and 2021. Data were collected using existing records and analysed using descriptive univariate analysis with statistical significance between the two sites determined using chi-squared test, p < 0.05. The overall data presented in this analysis show an overall ED mental health presentation rate of 12.02% for those who identified as 'Aboriginal but not Torres Strait Islander origin', 0.36% as 'Both Aboriginal and Torres Strait Islander' and 0.27% as 'Torres Strait Islander' totalling 12.63%. This is an overrepresentation compared to the regional population of 4.9%. One site recorded 14.1% of ED presentations that identified as Aboriginal and/or Torres Strait Islander, over double the site's demographic of 6.3%. Given the disproportionately high representation of First Nation people in MH-related ED presentations, further research is required to prioritise a First Nation research perspective that draws on First Nation research methods, such as yarning and storytelling to understand the unique cultural needs and challenges experienced by First Nation people accessing MH care via ED. Understanding the demographic is but one step in supporting the Cultural Safety needs of First Nation people. Additionally, research should be designed, governed and led by First Nation researchers.

Retail clinic visits and receipt of primary care.

BACKGROUND: An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care. OBJECTIVE: To assess the association between retail clinic use and receipt of key primary care functions. DESIGN: We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009. PATIENTS: We identified patients who had a visit for a simple acute condition in 2008, the "index visit". We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic. MAIN MEASURES: We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice-Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias. KEY RESULTS: Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice-Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management. CONCLUSIONS: Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.

Outpatient Foley catheter versus inpatient prostaglandin E2 gel for induction of labour: a randomised trial.

BACKGROUND: Induction of labour (IOL) is one of the commonest obstetric interventions, with significant impact on both the individual woman and health service delivery. Outpatient IOL is an attractive option to reduce these impacts. To date there is little data comparing outpatient and inpatient IOL methods, and potential safety concerns (hyperstimulation) if prostaglandins, the standard inpatient IOL medications, are used in the outpatient setting. The purpose of this study was to assess feasibility, clinical effectiveness and patient acceptability of outpatient Foley catheter (OPC) vs. inpatient vaginal PGE2 (IP) for induction of labour (IOL) at term. METHODS: Women with an unfavourable cervix requiring IOL at term (N=101) were randomised to outpatient care using Foley catheter (OPC, n=50) or inpatient care using vaginal PGE2 (IP, n=51). OPC group had Foley catheter inserted and were discharged overnight following a reassuring cardiotocograph. IP group received 2 mg/1 mg vaginal PGE2 if nulliparous or 1 mg/1 mg if multiparous. Main outcome measures were inpatient stay (prior to birth, in Birthing Unit, total), mode of birth, induction to delivery interval, adverse reactions and patient satisfaction. RESULTS: OPC group had shorter hospital stay prior to birth (21.3 vs. 32.4 hrs, p< .001), IP were more likely to achieve vaginal birth within 12 hours of presenting to Birthing Unit (53% vs. 28%, p= .01). Vaginal birth rates (66% OPC Vs. 71% IP), total induction to delivery time (33.5 hrs vs. 31.3 hrs) and total inpatient times (96 hrs OPC Vs. 105 hrs IP) were similar. OPC group felt less pain (significant discomfort 26% Vs 58%, p=.003), and had more sleep (5.8 Vs 3.4 hours, p< .001), during cervical preparation, but were more likely to require oxytocin IOL (88 Vs 59%, p=.001). CONCLUSIONS: OPC was feasible and acceptable for IOL of women with an unfavourable cervix at term compared to IP, however did not show a statistically significant reduction in total inpatient stay and was associated with increased oxytocin IOL. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN:12609000420246.

Association between Medicare Advantage plan star ratings and enrollment.

IMPORTANCE: The US Centers for Medicare & Medicaid Services publishes star ratings reflecting Medicare Advantage plan quality to inform enrollment decisions. OBJECTIVE: To assess the association between publicly reported Medicare Advantage plan quality ratings and enrollment. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 2011 Medicare Advantage enrollments among 952,352 first-time enrollees and 322,699 enrollees switching plans. MAIN OUTCOME MEASURE: Association between star ratings and enrollment was modeled using conditional logit regression, controlling for beneficiary and plan characteristics. RESULTS: Among the 952,352 included first-time enrollees, a 1-star higher rating was associated with a 9.5 (95% CI, 9.3-9.6) percentage-point increase in likelihood to enroll. The highest rating available to a beneficiary was associated with a 1.9 (95% CI, 1.8-2.1) percentage-point increase in likelihood to enroll. Among the 322,699 enrollees switching plans, a 1-star higher rating was associated with a 4.4 (95% CI, 4.2-4.7) percentage-point increase in likelihood to enroll. A rating at least as high as a beneficiary's prior plan was associated with a 6.3 (95% CI, 6.0-6.6) percentage-point increase in likelihood to enroll. Star ratings were less strongly associated with enrollment for black, rural, low-income, and the youngest beneficiaries. CONCLUSION AND RELEVANCE: Medicare's 5-star rating program for Medicare Advantage is associated with beneficiaries' enrollment decisions.

Nitrate limitation in early Neoproterozoic oceans delayed the ecological rise of eukaryotes.

The early Neoproterozoic Era witnessed the initial ecological rise of eukaryotes at ca. 800 Ma. To assess whether nitrate availability played an important role in this evolutionary event, we measured nitrogen isotope compositions (δ15N) of marine carbonates from the early Tonian (ca. 1000 Ma to ca. 800 Ma) Huaibei Group in North China. The data reported here fill a critical gap in the δ15N record and indicate nitrate limitation in early Neoproterozoic oceans. A compilation of Proterozoic sedimentary δ15N data reveals a stepwise increase in δ15N values at ~800 Ma. Box model simulations indicate that this stepwise increase likely represents a ~50% increase in marine nitrate availability. Limited nitrate availability in early Neoproterozoic oceans may have delayed the ecological rise of eukaryotes until ~800 Ma when increased nitrate supply, together with other environmental and ecological factors, may have contributed to the transition from prokaryote-dominant to eukaryote-dominant marine ecosystems.

The prospects of poop: a review of past achievements and future possibilities in faecal isotope analysis.

What can the stable isotope values of human and animal faeces tell us? This often under-appreciated waste product is gaining recognition across a variety of disciplines. Faecal isotopes provide a means of monitoring diet, resource partitioning, landscape use, tracking nutrient inputs and cycling, and reconstructing past climate and environment. Here, we review what faeces are composed of, their temporal resolution, and how these factors may be impacted by digestive physiology and efficiency. As faeces are often used to explore diet, we clarify how isotopic offsets between diet and faeces can be calculated, as well as some differences among commonly used calculations that can lead to confusion. Generally, faecal carbon isotope (δ13 C) values are lower than those of the diet, while faecal nitrogen isotope values (δ15 N) values are higher than in the diet. However, there is considerable variability both within and among species. We explore the role of study design and how limitations stemming from a variety of factors can affect both the reliability and interpretability of faecal isotope data sets. Finally, we summarise the various ways in which faecal isotopes have been applied to date and provide some suggestions for future research. Despite remaining challenges, faecal isotope data are poised to continue to contribute meaningfully to a variety of fields.

Barriers primary care clinic leaders face to improving value in a consumer choice health plan design.

Primary care clinics are a frequent focus of policy initiatives to improve the value of health care; yet, it is unclear whether they have the ability or incentive to take on the additional tasks that these initiatives ask of them. This paper reports on a qualitative study assessing barriers that clinic leaders face to reducing cost within a tiered cost-sharing commercial health insurance benefit design that gives both consumers and clinics a strong incentive to reduce cost. We conducted semi-structured interviews of clinical and operational leaders at a diverse set of 12 Minnesota primary care clinics and identified 6 barriers: insufficient information on drivers of cost; clinics controlling a portion of spending; patient preference for higher cost specialists; administrative challenges; limited resources; and misalignment of incentives. We discuss approaches to reducing these barriers and opportunities to implement them.

Physician organizations' use of behavioral nudges to influence physician behavior.

OBJECTIVES: Because physicians' decisions drive health care costs and quality, there is growing interest in applying behavioral economics approaches, including behavioral nudges, to influence physicians' decisions. This paper investigates adoption of behavioral nudges by health system-affiliated physician organizations (POs), types of nudges being used, PO leader perceptions of nudge effectiveness, and implementation challenges. STUDY DESIGN: Mixed-methods study design (PO leader survey followed by in-depth qualitative interviews). Purposive sample of 30 health system-affiliated POs in 4 states; POs varied in size and quality performance. METHODS: We collected data between October 2017 and June 2019. The survey asked PO leaders to report their organization's use of 5 categories of nudges to influence primary and specialty physicians' actions. We conducted semistructured phone interviews to confirm survey responses, elicit examples of the nudges that POs reported using, understand how nudges were structured, and identify implementation challenges. We present descriptive tabulations of nudge use and effectiveness ratings. We applied thematic analysis to the interview data. RESULTS: Almost all POs in this study reported nudge use. Clinical templates, patient action lists, and altered order entry were most commonly used. However, PO leaders reported that nudge use was limited to a narrow range of clinical applications, not widespread across the organization, and mostly structured as suggestions rather than default actions or hard stops. CONCLUSIONS: Nudge use remains limited in practice. Opportunities exist to expand use of nudges to influence physician behavior; however, expanding use of behavioral nudges will require PO investment of resources to support their construction and maintenance.

Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems.

Importance: Public and private payers continue to expand use of alternative payment models, aiming to use value-based payment to affect the care delivery of their contracted health system partners. In parallel, health systems and their employment of physicians continue to grow. However, the degree to which health system physician compensation reflects an orientation toward value, rather than volume, is unknown. Objective: To characterize primary care physician (PCP) and specialist compensation arrangements among US health system-affiliated physician organizations (POs) and measure the portion of total physician compensation based on quality and cost performance. Design Setting and Participants: This study was a cross-sectional mixed-methods analysis of in-depth multimodal data (compensation document review, interviews with 40 PO leaders, and surveys conducted between November 2017 and July 2019) from 31 POs affiliated with 22 purposefully selected health systems in 4 states. Data were analyzed from June 2019 to September 2020. Main Outcomes and Measures: The frequency of PCP and specialist compensation types and the percentage of compensation when included, including base compensation incentives, quality and cost performance incentives, and other financial incentives. The top 3 actions physicians could take to increase their compensation. The association between POs' percentage of revenue from fee-for-service and their physicians' volume-based compensation percentage. Results: Volume-based compensation was the most common base compensation incentive component for PCPs (26 POs [83.9%]; mean, 68.2% of compensation; median, 81.4%; range, 5.0%-100.0% when included) and specialists (29 POs [93.3%]; mean, 73.7% of compensation; median, 90.5%; range, 2.5%-100.0% when included). While quality and cost performance incentives were common (included by 83.9%-56.7% of POs for PCPs and specialists, respectively), the percentage of compensation based on quality and cost performance was modest (mean, 9.0% [median, 8.3%; range, 1.0%-25.0%] for PCPs and 5.3% [median, 4.5%; range, 0.5%-16.0%] for specialists when included). Increasing the volume of services was the most commonly cited action for physicians to increase compensation, reported as the top action by 22 POs (70.0%) for PCPs and specialists. We observed a very weak, nonsignificant association between the percentage of revenue of POs from fee for service and the PCP and specialist volume-based compensation percentage (r = 0.08; P = .78 and r = -0.04; P = .89, respectively). Conclusions and Relevance: The results of this cross-sectional study suggest that PCPs and specialists despite receiving value-based reimbursement incentives from payers, the compensation of health system PCPs and specialists was dominated by volume-based incentives designed to maximize health systems revenue.

The ethics of obtaining consent in labour for research.

BACKGROUND: It is widely acknowledged that the pregnant population is a vulnerable and potentially disadvantaged one with regard to research. We sought to evaluate compliance with this concept by examining current Australian practices of obtaining consent for research during labour through the published literature and from Australian Human Research Ethics Committees (HRECs) as well as reviewing the relevant literature. METHODS: We surveyed Australian HRECs requesting information about their opinions and/or practices surrounding the ethics of research consent during labour or birth. In addition, a literature search was performed to find randomised controlled trials (RCTs) involving interventions during labour in Australia in the last five years. RESULTS: Of the HREC respondents, 75% believed it to be ethical to obtain consent for research in labour, 87% would require additional expert assistance to approve, 57% felt the partner should be involved and all proposed research scenarios were thought to require protocol changes. Recent local RCTs reflected a variety of consent strategies, each having their limitations. CONCLUSIONS: An under-used but potentially useful strategy may be staged recruitment and consent. Despite the evidence supporting labour as a time requiring increased acuity for informed consent, there is little to suggest that this knowledge is being applied to current Australian HREC and RCT practices. We suggest that further practical guidelines be devised to aid researchers and human ethics committees.