Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models.

The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient's multifaceted care team as well as acting as the mayor of the "medical neighborhood," leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI's goal.

RNA-seq analysis of the mantle transcriptome from Mytilus edulis during a seasonal spawning event in deep and shallow water culture sites on the northeast coast of Newfoundland, Canada.

The blue mussel (Mytilus edulis) has global commercial and ecological importance both in wild and cultured conditions. However there is a qualitative and quantitative lack of knowledge of the molecular mechanisms associated with its reproductive physiology, especially with reference to environmental interactions. Here we initiated a transcriptomic analysis (RNA-sequencing (RNA-seq)) of the mantle from both sexes sampled during a seasonal spawning event and from two culture depths (shallow-5 m; deep- 15 m). Mantle libraries were produced from 3 males and 3 females sampled from each of two shallow sites and two deep sites for a total of 12 replicate male and 12 replicate female libraries (24 total libraries). Overall a total of 2.3 billion raw 100 base reads with an average of 96.5 million reads/library were obtained and assembled into 296,118 transcripts with an average length of 568 bp. Overall, 315 transcripts from male libraries and 25 from female libraries were found to be upregulated in deep water as compared to shallow (edgeR adjusted p value ≤ 0.05). Conversely, 126 transcripts from male libraries and 135 from female libraries were found to be significantly downregulated at the same depth. Thirteen transcripts were selected for qPCR validation based on importance in reproduction, antimicrobial defense and metabolism. Of these, 9 RNA-seq identified transcripts were shown by qPCR to be differentially expressed between groups: 2 were upregulated in deep compared with shallow water (dhx38, mt-co1), 2 were upregulated for female compared with male mantle (pias2, mapkap1) and 6 genes (fndc3a, acbd3, klhl10, ccnb3, armc4, mt-co1) showed to be upregulated in males compared to females. The majority of qPCR studied transcripts were identified as involved in gamete development based on the UniProt database. This study further characterizes the importance of the mantle transcriptome during reproductive activities of M. edulis.

Lives in isolation: stories and struggles of low-income African American women with panic disorder.

Research evidence points to the existence of racial-ethnic disparities in both access to and quality of mental health services for African Americans with panic disorder. Current panic disorder evaluation and treatment paradigms are not responsive to the needs of many African Americans. The primary individual, social, and health-care system factors that limit African Americans' access to care and response to treatment are not well understood. Low-income African American women with panic disorder participated in a series of focus-group sessions designed to elicit (1) their perspectives regarding access and treatment barriers and (2) their recommendations for designing a culturally consistent panic treatment program. Fear of confiding to others about panic symptoms, fear of social stigma, and lack of information about panic disorder were major individual barriers. Within their social networks, stigmatizing attitudes toward mental illness and the mentally ill, discouragement about the use of psychiatric medication, and perceptions that symptoms were the result of personal or spiritual weakness had all interfered with the participants' treatment seeking efforts and contributed to a common experience of severe social isolation. None of the focus-group members had developed fully effective therapeutic relationships with either medical or mental health providers. They described an unmet need for more interactive and culturally authentic relationships with treatment providers. Although the focus-group sessions were not intended to be therapeutic, the women reported that participation in the meetings had been an emotionally powerful and beneficial experience. They expressed a strong preference for the utilization of female-only, panic disorder peer-support groups as an initial step in the treatment/recovery process. Peer-support groups for low-income African American women with panic disorder could address many of the identified access and treatment barriers.

Assessing the impact of streaming in a regional emergency department.

OBJECTIVE: To evaluate the impact of a streaming model, previously validated in metropolitan EDs, on selected performance indicators in a regional ED. METHOD: Multiple linear regression models were applied to monthly time series data from 43 months prior to the intervention and 15 months following the intervention to measure the impact of the streaming model on the following performance indicators: (i) percentage of emergency patients admitted to an inpatient bed within 8 h; (ii) percentage of non-admitted emergency patients with a length of stay of less than 4 h; and (iii) percentage of emergency patients who left without being seen by a doctor or nurse practitioner. SETTING: Bendigo Health ED in regional Victoria. RESULTS: Prior to the introduction of streaming, there was a downward trend in both the percentage of emergency patients admitted to an inpatient bed within 8 h, and the percentage of non-admitted emergency patients with a length of stay of less than 4 h. After the introduction of streaming, these trends were reversed (P = 0.008 and P = 0.004, respectively). There was no statistically significant change in the trend associated with the percentage of emergency patients who left without being seen (P = 0.904). CONCLUSIONS: The implementation of the streaming model had an impact on the two performance indicators associated with length of stay in this regional ED, but did not have a significant impact (positive or negative) on the percentage of patients who did not wait to be seen. These results might interest other EDs in regional hospitals.

Physical and emotional predictors of depression after radical prostatectomy.

Radical prostatectomy commonly results in urinary, sexual, and bowel dysfunction that bothers men and may lead to depressive symptomatology (hereafter depression) that occurs at a rate 4 times greater for men with prostate cancer than healthy counterparts. The purpose of this study was to assess depressive symptoms in men shortly after radical prostatectomy and to identify associated risk factors. Seventy-two men were interviewed 6 weeks after surgery. Measured were depression (Geriatric Depression Scale), self-efficacy (Stanford Inventory of Cancer Patient Adjustment), social support (Modified Inventory of Socially Supportive Behaviors), physical and emotional factors (UCLA Prostate Cancer Index), and social function (SF-36 subscale). Results indicate that men with high self-efficacy and less sexual bother were 45% and 55% less likely to have depressive symptoms, respectively. Findings from this study add to the limited amount of information on the complex relationship between prostate cancer treatment and depression in men.

Dyadic support and quality-of-life after radical prostatectomy.

BACKGROUND: Treatment side effects after radical prostatectomy include urinary, sexual, and bowel dysfunction. These functional declines, coupled with the bother associated with these dysfunctions, lead to a complicated pattern of change in quality-of-life and decreased self-efficacy. METHODS: In this study, 72 men who underwent radical prostatectomy 6-weeks prior were randomly assigned to usual health care control group or peer-to-peer support (dyadic support) group. The dyadic meetings were held once a week for 8 weeks. Measured pre- and post-test was general health-related quality-of-life (SF-36), prostate cancer-specific quality-of-life (UCLA Prostate Cancer Index), and self-efficacy (Stanford Inventory of Cancer Patient Adjustment). RESULTS: By 8 weeks, self-efficacy significantly improved for men in the experimental group, but not for men in the control group. A series of logistic regression analyses showed that the dyadic intervention significantly accounted for changes in physical role functioning, bowel function, mental health, and social function. Age, education, and self-efficacy had significant interaction effects and increased the effects of the dyadic intervention on several outcomes. CONCLUSIONS: The intervention had a significant impact on how men react socially and emotionally to the side effects of radical prostatectomy.

The impact of dyadic social support on self-efficacy and depression after radical prostatectomy.

OBJECTIVE: To assess the effect of one-on-one peer support at enhancing self-efficacy and decreasing depression in older men treated by radical prostatectomy for prostate cancer. METHODS: Six weeks after surgery, 72 men (M(age) = 60) were randomly assigned to a treatment (n = 37) or control group ( n = 35). Treatment group participants were paired to form dyads with a trained support partner who had similar treatment and related side effects; control group participants received usual health care. Dyads met 8 times over 8 weeks to discuss concerns and coping strategies. RESULTS: At posttest, the treatment group had significantly higher self-efficacy than the controls (M = 328.89 and M = 304.54, respectively) and significantly less depression (M = 0.92 and M = 2.49, respectively). Depression outcomes remained significant when controlling baseline self-efficacy and social support (F = 4.845, p = .032). DISCUSSION: Findings confirm pilot study results and are theoretically consistent with the self-efficacy enhancing nature of vicarious experience described by Bandura in self-efficacy theory.

Asymptomatic bacteriuria and intimate partner violence in pregnant women.

OBJECTIVE: This study was undertaken to determine whether the association of intimate partner violence with urinary tract infection and pyelonephritis in pregnancy is due to a higher rate of asymptomatic bacteriuria in those suffering intimate partner violence. STUDY DESIGN: Women enrolling in prenatal care had urine collected for quantitative culture (n = 342) and completed 2 scales with a computer-based survey system: The Conflict Tactics Scale for verbal and physical abuse and the Castro survey for sexual abuse. RESULTS: The prevalence of verbal abuse during pregnancy was 46.9%, physical abuse, 7.6%, sexual abuse 5.8%. No significant associations were seen between quantitative culture of uropathogens and verbal, physical, or sexual abuse. CONCLUSION: It is unlikely that the reason for the association of urinary tract infection and intimate partner violence is due to a higher number of uropathogens present in the urine of women with verbal, physical, or sexual abuse.

Ethnic differences in the reliability and validity of a Panic Disorder Screen.

PURPOSE: The purpose of this study was to compare the reliability and validity of the Brief Panic Disorder Screen (BPDS) in samples of African American and Caucasian American primary care patients. METHODS: The BPDS was administered to 295 patients scheduled to visit a primary care clinic for medical reasons. The presence or absence of a panic disorder diagnosis was established during a clinical interview with a psychiatrist. Measures of reliability (internal consistency) and validity (criterion validity) were compared between the two ethnic subgroups. FINDINGS: The BPDS demonstrated greater reliability and validity for Caucasians than African Americans. This effect was maintained even after controlling for group differences in key demographic variables. Differences between ethnic groups were apparent in both those with and those without panic disorder (PD). BPDS responses of African Americans with PD demonstrated very low internal consistency whereas a high rate of false positive PD diagnoses was related to higher than expected BPDS scores among African Americans without PD, particularly on the level of fear felt when experiencing shortness of breath or heart palpitations. DISCUSSION: These findings support the notion that cultural differences in the language and meaning associated with anxiety disorders contribute to the difficulty of accurately diagnosing PD in primary care populations. Additional research is needed to provide a better understanding of the cultural aspects of the anxiety experience. Such research would facilitate the development of better screening tools for panic and other anxiety disorders for ethnic minority primary care populations.

Urinary, sexual, and bowel dysfunction and bother after radical prostatectomy.

INTRODUCTION: Radical prostatectomy results in greater persistence of urinary and sexual dysfunction (and to a minor degree, bowel dysfunction) than other forms of prostate cancer treatment. These physical side effects create bother, which is the degree of annoyance, dysfunction, or discomfort associated with treatment aftermath. OBJECTIVE: The purpose of this study was to assess the relationships between post-radical prostatectomy urinary, sexual, and bowel dysfunction, and the resultant bother to determine which of the physical dysfunctions bothers men the most. METHOD: Seventy-two men were recruited and surveyed 6 weeks after radical prostatectomy. Outcome measures included self-efficacy (Stanford Inventory of Cancer Patient Adjustment), social support (Modified Inventory of Socially Supportive Behaviors), uncertainty (Uncertainty in Illness Scale), and physical function and bother (UCLA Prostate Cancer Index). RESULTS: Sexual dysfunction had the highest prevalence among treatment side effects caused by radical prostatectomy. However, it was urinary dysfunction in terms of incontinence that was the most bothersome. CONCLUSIONS: Given various treatment options for prostate cancer, men who undergo radical prostatectomy initially decide that the physical dysfunction is worth the benefits of improved likelihood of survival; however, they do so without firsthand knowledge of the associated bother. Patients should be informed of the transient and unrelenting physical symptoms and associated bother that are produced after radical prostatectomy.

Routine history as compared to audio computer-assisted self-interview for prenatal care history taking.

OBJECTIVE: To compare endorsement rates obtained with audio computer-assisted self-interview versus routine prenatal history. STUDY DESIGN: A crosssectional study compared items captured with the routine history to those captured with a computer interview (computer screen displaying and computer audio reading questions, with responses entered by touch screen). The subjects were women (n=174) presenting to a public hospital clinic for prenatal care. RESULTS: The prevalence of positive responses using the computer interview was significantly greater (p < 0.01) than with the routine history for induced abortion (16.8% versus 4.0%), lifetime smoking (12.8% versus 5.2%), intimate partner violence (10.0% versus 2.4%), ectopic pregnancy (5.2% versus 1.1%) and family history of mental retardation (6.7% versus 0.6%). Significant differences were not found for history of spontaneous abortion, hypertension, epilepsy, thyroid disease, smoking during pregnancy, gynecologic surgery, abnormal Pap test, neural tube defect or cystic fibrosis family history. However, in all cases, prevalence was equal or greater with the computer interview. CONCLUSION: Women were more likely to report sensitive and high-risk behavior, such as smoking history, intimate partner violence and elective abortion, with the computer interview. The computer interview displayed equal or increased patient reporting of positive responses and may therefore be an accurate method of obtaining an initial history.

Differences in the indicators of depressive symptoms among a community sample of African-American and Caucasian older adults.

Depression among older adults is a major public health concern in the U.S. Yet, time and again this condition goes undiagnosed, or attributed to other causes. Despite being treatable, few individuals older than age 65 are treated for this disorder. Using a community sample of 404 African-American and Caucasian older adults, the aim of this study was to identify the sources of racial group variance in self-reports of depressive symptoms. Descriptive and multivariate analyses reveal no racial/ethnic differences in the mean level of depressive symptoms, but differences in the correlates of self-reported depression, as well as differences in the distribution of individual indicators of depressive symptoms.

Knowledge, behaviors, and attitudes about hearing loss and hearing protection among racial/ethnically diverse young adults.

Over 11 million individuals exhibit some degree of permanent noise induced hearing loss (NIHL). Despite such data, there remains a paucity of empirical evidence on the knowledge of noise exposure and hearing protection devices (HPDs) for young adults, particularly those of diverse racial/ethnic backgrounds. This lack of research is unfortunate, as prior research suggests that the incidence of NIHL can be reduced through educational programs, such as hearing conservation programs (HCPs). Moreover, research also indicates that such educational programs are more beneficial when developed for specific age and/or ethnic/racial groups. The primary aim of this investigation was to determine the knowledge base of 200 college-aged young adults aged 18-29, concerning the auditory mechanism, NIHL, and the use of HPDs. The second aim of this study was to identify race and ethnicity differences or similarities in knowledge of these areas among African-American and caucasian young adults. Overall, in many instances, a majority of the young adults in our study demonstrated a high degree of knowledge concerning factors associated with exposure to excessive noise and the risk of hearing loss. Yet, the results also revealed significant racial/ethnic differences in knowledge, behaviors, and attitudes about the use of HPDs. Recent estimates suggest that more than 11 million individuals in the United States exhibit some degree of NIHL. Moreover, 40 million individuals work in environments that contain potentially harmful noise levels, and over 50 million Americans routinely use firearms--a common cause of noise-induced hearing impairment. A specific hallmark manifestation of NIHL is a permanent decrease in hearing sensitivity from 3,000-6,000 Hz, with a characteristic notch at 4,000 Hz. Additional effects of exposure to high noise levels include physiological changes in heart rate and blood pressure, decrease in work productivity, and an interference with communication that results from the masking of speech. With these considerations in mind, the purpose of this study was to investigate the knowledge, behaviors, and attitudes of a young-adult population in the United States concerning the factors that contribute to NIHL and the use of hearing protection. Additionally, this study was interested in whether there were racial/ethnic differences or similarities in knowledge of hearing loss and the use of HPDs among African-American and caucasian young adults.

Parental explanatory models of ADHD: gender and cultural variations.

BACKGROUND: This study describes parents' explanatory models of Attention Deficit Hyperactivity Disorder (ADHD) and examines model variation by child characteristics. METHOD: Children with ADHD (N = 182) were identified from a school district population of elementary school students. A reliable coding system was developed for parental responses obtained in ethnographic interviews in order to convert qualitative into numerical data for quantitative analysis. RESULTS: African-American parents were less likely to connect the school system to ADHD problem identification, expressed fewer worries about ADHD-related school problems, and voiced fewer preferences for school interventions than Caucasian parents, pointing to a potential disconnect with the school system. CONCLUSIONS: More African-American than Caucasian parents were unsure about potential causes of and treatments for ADHD, indicating a need for culturally appropriate parent education approaches.