Financial Performance of Accountable Care Organizations: A 5-Year National Empirical Analysis.

GOALS: Of 513 accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) in 2020, 67% generated a positive shared savings of approximately $2.3 billion. This research aimed to examine their financial performance trends and drivers over time. METHODS: The unit of analysis was the ACO in each year of the study period from 2016 to 2020. The dependent variable was the ACOs' total shared savings earned annually per beneficiary. The independent variables included ACO age, risk model, clinician staffing type, and provider type (hybrid, hospital-led, or physician-led). Covariates were the average risk score among beneficiaries, payer type, and calendar year. The Centers for Medicare & Medicaid Services (CMS) public use files (PUFs) and a commercial healthcare data aggregator were the data sources. RESULTS: ACOs' earned shared savings grew annually by 35%, while the proportions of ACOs with positive shared savings grew by 21%. For 1-year increase in ACO age, an additional $0.57 of shared savings per beneficiary was observed. ACOs with two-sided risk contracting were associated with an average marginal increase of $109 in shared savings per beneficiary compared to ACOs with one-sided risk contracting. Primary care physicians were associated with the greatest increase in earned shared savings per beneficiary. In contrast, nurse practitioners/physician assistants/clinical nurse specialists were associated with a reduction in earned shared savings. Under a one-sided risk model, hospital-led ACOs were associated with $18 higher average shared savings earning per beneficiary compared to hybrid ACOs, while physician-led ACOs were associated with lower average saved shared earnings per beneficiary at -$2 compared to hybrid ACOs. Provider-type results were not statistically significant at the 5% nominal level. No statistically significant differences were observed between provider types under a two-sided risk model. PRACTICAL APPLICATIONS: For all ACO provider types, building broader primary care provider networks was correlated with positive financial results. Future research should examine whether ACOs are conducting specific preventive screenings for cancer or monitoring conditions such as diabetes, hypertension, heart disease, obesity, mental disorders, and joint disorders. Such studies may answer health policy and strategy questions about the effects of incentives for improved ACO performance in serving a healthier population.

Near-Perfect Automation: Investigating Performance, Trust, and Visual Attention Allocation.

OBJECTIVE: Assess performance, trust, and visual attention during the monitoring of a near-perfect automated system. BACKGROUND: Research rarely attempts to assess performance, trust, and visual attention in near-perfect automated systems even though they will be relied on in high-stakes environments. METHODS: Seventy-three participants completed a 40-min supervisory control task where they monitored three search feeds. All search feeds were 100% reliable with the exception of two automation failures: one miss and one false alarm. Eye-tracking and subjective trust data were collected. RESULTS: Thirty-four percent of participants correctly identified the automation miss, and 67% correctly identified the automation false alarm. Subjective trust increased when participants did not detect the automation failures and decreased when they did. Participants who detected the false alarm had a more complex scan pattern in the 2 min centered around the automation failure compared with those who did not. Additionally, those who detected the failures had longer dwell times in and transitioned to the center sensor feed significantly more often. CONCLUSION: Not only does this work highlight the limitations of the human when monitoring near-perfect automated systems, it begins to quantify the subjective experience and attentional cost of the human. It further emphasizes the need to (1) reevaluate the role of the operator in future high-stakes environments and (2) understand the human on an individual level and actively design for the given individual when working with near-perfect automated systems. APPLICATION: Multiple operator-level measures should be collected in real-time in order to monitor an operator's state and leverage real-time, individualized assistance.

An investigation of cardiac vagal tone over time and its relation to vigilance performance: a growth curve modeling approach.

Introduction: Research over the last couple of decades has demonstrated a relationship between psychophysiological measures, specifically cardiac functions, and cognitive performance. Regulation of the cardiac system under parasympathetic control is commonly referred to as cardiac vagal tone and is associated with the regulation of cognitive and socioemotional states. The goal of the current study was to capture the dynamic relationship between cardiac vagal tone and performance in a vigilance task. Method/Results: We implemented a longitudinal growth curve modeling approach which unveiled a relationship between cardiac vagal tone and vigilance that was non-monotonic and dependent upon each person. Discussion: The findings suggest that cardiac vagal tone may be a process-based physiological measure that further explains how the vigilance decrement manifests over time and differs across individuals. This contributes to our understanding of vigilance by modeling individual differences in cardiac vagal tone changes that occur over the course of the vigilance task.

An examination of relations between baseline pupil measures and cognitive abilities.

Examining individual differences in pupil size and pupillary dynamics have revealed important insights into the nature of individual differences in cognitive abilities like working memory capacity, long-term memory, attention control, and fluid intelligence. These findings are often tied to the locus coeruleus-norepinephrine (LC-NE) system, as this system has a tight temporal correlation with pupil diameter. Some recent research has demonstrated positive correlations between resting pupil size and cognitive ability, specifically fluid intelligence. The present study attempted to replicate such relations. Across three studies, a large sample of participants (N = 845) completed batteries of cognitive ability measures and measures of resting pupil size and pupillary hippus (fluctuations in pupil diameter). The cognitive measures comprised tasks previously used to measure attention control, visual short-term memory capacity, fluid intelligence, working memory capacity, and visuospatial ability. At the factor level, cognitive ability and pupil size correlated near zero. We did observe some limited evidence for a negative correlation between resting pupillary hippus and cognitive ability. Given the null findings in the present data, we encourage further replication of relations between resting pupil measures and cognitive abilities before making any strong theoretical conclusions about such relations.

The Current State of Subjective Training Load Monitoring: Follow-Up and Future Directions.

This article addresses several key issues that have been raised related to subjective training load (TL) monitoring. These key issues include how TL is calculated if subjective TL can be used to model sports performance and where subjective TL monitoring fits into an overall decision-making framework for practitioners. Regarding how TL is calculated, there is conjecture over the most appropriate (1) acute and chronic period lengths, (2) smoothing methods for TL data and (3) change in TL measures (e.g., training stress balance (TSB), differential load, acute-to-chronic workload ratio). Variable selection procedures with measures of model-fit, like the Akaike Information Criterion, are suggested as a potential answer to these calculation issues with examples provided using datasets from two different groups of elite athletes prior to and during competition at the 2016 Olympic Games. Regarding using subjective TL to model sports performance, further examples using linear mixed models and the previously mentioned datasets are provided to illustrate possible practical interpretations of model results for coaches (e.g., ensuring TSB increases during a taper for improved performance). An overall decision-making framework for determining training interventions is also provided with context given to where subjective TL measures may fit within this framework and the determination if subjective measures are needed with TL monitoring for different sporting situations. Lastly, relevant practical recommendations (e.g., using validated scales and training coaches and athletes in their use) are provided to ensure subjective TL monitoring is used as effectively as possible along with recommendations for future research.

Limitations of current spatial ability testing for military aviators.

Spatial ability has long been considered an important attribute when identifying military aviators. This paper examines the Direction Orientation Task (DOT), which is currently used by the US military to assess spatial ability in aviation applicants. Several limitations of the test, such as a limited number of trials and the availability of practice trials online, make it subject to potential ceiling effects. The paper presents historical data of all Naval Aviator applicants over a six-year time period and revealed that 22% of applicants answered 90% or more of the questions correctly. Furthermore, test performance has significantly increased in the years since the test was first administered and there is evidence that DOT is no longer contributing incremental validity. A follow-up empirical study looked at DOT performance and strategy in a group of military student aviators and student air traffic controllers. The results of the empirical investigation reveal that the use of an analytic strategy was associated with higher performance on the DOT, whereas the use of a spatial strategy was not associated with performance. Taken together, the improved performance data over time and the data on strategy use suggest the test's ability to measure spatial ability may be diminishing, ultimately reducing its construct and incremental validity. This is problematic and should be addressed, since the DOT is the only measure of spatial ability used by the Navy to assess aviation applicants.

Training Load, Heart Rate Variability, Direct Current Potential and Elite Long Jump Performance Prior and during the 2016 Olympic Games.

The primary objective of this investigation was to investigate the relationships between training load (TL), heart rate variability (HRV) and direct current potential (DC) with elite long jump performance prior to and during the 2016 Olympics Games. Sessional ratings of perceived exertion (sRPE), training duration, HRV and DC were collected from four elite athletes (26.4 ± 1.4 years, height 1.83 ± 0.05 m, weight 68.9 ± 5.0 kg) for a 16-week period in qualification for and competition at the 2016 Olympic Games. Acute and chronic TL, training stress balance and differential load were calculated with three different smoothing methods. These TL measures along with HRV and DC were examined for their relationship to intra-athlete performance using repeated measure correlations and linear mixed models. Successful compared to unsuccessful intra-athlete performances were characterised by a higher chronic TL (p < 0.01, f2 = 0.31) but only when TL was exponentially smoothed. There were also negative correlations between HRV and performance (r = -0.55, p < 0.01) and HRV was significantly lower for more successful performances (p < 0.01, f2 = 0.19). Exponentially smoothed chronic TL was significantly higher and HRV was significantly lower for successful intra-athlete performances prior and during the 2016 Olympics Games in an elite group of long jump athletes. Monitoring sRPE and HRV measures and manipulating TL prior to competition seems worthwhile for elite long jump athletes.

The Influence of Mental Fatigue on Sessional Ratings of Perceived Exertion in Elite Open and Closed Skill Sports Athletes.

ABSTRACT: Coyne, JOC, Coutts, AJ, Newton, RU, and Haff, GG. The influence of mental fatigue on sessional ratings of perceived exertion in elite open and closed skill sports athletes. J Strength Cond Res 35(4): 963-969, 2021-The main purpose of this investigation was to examine influence of mental fatigue on sessional ratings of perceived exertion (sRPE) over a training week in elite athletes in open skill (OS, i.e., more unpredictable and externally paced sports) and closed skill (CS, i.e., more predictable and internally paced) sports. Visual analogue scales for mental fatigue, sRPE (CR-10 scale), and training duration were collected from an OS group (n = 27) of basketball and volleyball athletes and a CS group (n = 28) of weightlifting and track and field athletes during a typical training week 5 months before the 2016 Olympic Games. These variables were then examined using repeated measure correlations and linear mixed models with the level of significance set for the study at p < 0.05. There was a small significant correlation between mental fatigue and sRPE in the OS group (r = 0.23, p < 0.01), but not in the CS group (r = -0.07, p = 0.38). Mental fatigue had trivial influence on sRPE during individual sessions, but had a moderate effect on total sRPE over a week (p < 0.001, f2 = 0.265) when accounting for type of sport, training duration, and injury/illness burden. It seems mental fatigue may not significantly influence sRPE in individual training sessions, but may potentially have a cumulative effect that may affect the sRPE over a training week. This suggests monitoring mental fatigue independently of other training load (TL) measures may be worthwhile for strength and conditioning specialists and sports coaches to manage their athletes and researchers conducting studies into TL and performance.

Relationships Between Different Internal and External Training Load Variables and Elite International Women's Basketball Performance.

PURPOSE: To investigate the relationships between internal and external training load (TL) metrics with elite international women's basketball performance. METHODS: Sessional ratings of perceived exertion, PlayerLoad™/minute, and training duration were collected from 13 elite international-level female basketball athletes (age 29.0 [3.7] y, stature 186.0 [9.8] cm, body mass 77.9 [11.6] kg) during the 18 weeks prior to the International Basketball Federation Olympic qualifying event for the 2016 Rio Olympic Games. Training stress balance, differential load, and the training efficiency index were calculated with 3 different smoothing methods. These TL metrics and their change in the last 21 days prior to competition were examined for their relationship to competition performance as coach ratings of performance. RESULTS: For a number of TL variables, there were consistent significant small to moderate correlations with performance and significant small to large differences between successful and unsuccessful performances. However, these differences were only evident for external TL when using exponentially weighted moving averages to calculate TL. The variable that seemed most sensitive to performance was the change in training efficiency index in the last 21 days prior to competition (performance r = .47-.56, P < .001 and difference between successful and unsuccessful performance P < .001, f2 = 0.305-0.431). CONCLUSIONS: Internal and external TL variables were correlated with performance and distinguished between successful and unsuccessful performances among the same players during international women's basketball games. Manipulating TL in the last 3 weeks prior to competition may be worthwhile for basketball players' performance, especially in internal TL.

Relationships Between Internal Training Load in a Taper With Elite Weightlifting Performance Calculated Using Different Moving Average Methods.

PURPOSE: A simple and 2 different exponentially weighted moving average methods were used to investigate the relationships between internal training load and elite weightlifting performance. METHODS: Training impulse data (sessional ratings of perceived exertion × training duration) were collected from 21 elite weightlifters (age = 26.0 [3.2] y, height = 162.2 [11.3] cm, body mass = 72.2 [23.8] kg, previous 12-mo personal best total 96.3% [2.7%] of world record total) during the 8 weeks prior to the 2016 Olympic Games qualifying competition. The amount of training modified or cancelled due to injury/illness was also collected. The training stress balance (TSB) and acute to chronic workload ratio (ACWR) were calculated with the 3 moving average methods. Along with the amount of modified training, TSB and ACWR across the moving average methods were then examined for their relationship to competitive performance. RESULTS: There were no consistent associations between performance and training load on the day of competition. The volatility (SD) of the ACWR in the last 21 days preceding the competition was moderately correlated with performance across moving average methods (r = -.41 to .48, P = .03-.07). TSB and ACWR volatility in the last 21 days were also significantly lower for successful performers but only as a simple moving average (P = .03 and .03, g = 1.15 and 1.07, respectively). CONCLUSIONS: Practitioners should consider restricting change and volatility in an athlete's TSB or ACWR in the last 21 days prior to a major competition. In addition, a simple moving average seemed to better explain elite weightlifting performance than the exponentially weighted moving averages in this investigation.

Successes and failures with bundled payments in the commercial market.

The relatively few examples of commercially funded condition-specific bundled payments provide insights into how to spread this alternative payment model further in the private insurance market.

Heart Rate Variability and Direct Current Measurement Characteristics in Professional Mixed Martial Arts Athletes.

This study's purpose was to examine heart rate variability (HRV) and direct current potential (DC) measures' sensitivity and correlations between changes in the acute recovery and stress scale (ARSS) and the previous day's training load. Training load, HRV, DC and ARSS data were collected from fourteen professional mixed martial arts athletes (32.6 ± 5.3 years, 174.8 ± 8.8 cm, 79.2 ± 17.5 kg) the following morning after hard, easy and rest days. Sensitivity was expressed as a signal-to-noise ratio (SNR, inter-day typical error (TE) or coefficient of variation (%CV) divided by intra-day TE or %CV). Correlations between HRV, DC and ARSS with training load were also examined. The SNRs for the various HRV and DC measures were acceptable to good (1.02-2.85). There was a 23.1% CV average increase between measures taken between different locations versus the same location. Training load changes were not correlated with HRV/DC but were correlated with ARSS stress variables. Practitioners should be aware of HRV/DC variability; however the daily training signal was greater than the test-retest error in this investigation. Upon awakening, HRV/DC measures appear superior for standardization and planning. HRV and DC measures were less sensitive to the previous day's training load than ARSS measures.

Does Mathematical Coupling Matter to the Acute to Chronic Workload Ratio? A Case Study From Elite Sport.

PURPOSE: Criticisms of the acute to chronic workload ratio (ACWR) have been that the mathematical coupling inherent in the traditional calculation of the ACWR results in a spurious correlation. The purposes of this commentary are (1) to examine how mathematical coupling causes spurious correlations and (2) to use a case study from actual monitoring data to determine how mathematical coupling affects the ACWR. METHODS: Training and competition workload (TL) data were obtained from international-level open-skill (basketball) and closed-skill (weightlifting) athletes before their respective qualifying tournaments for the 2016 Olympic Games. Correlations between acute TL, chronic TL, and the ACWR as coupled/uncoupled variations were examined. These variables were also compared using both rolling averages and exponentially weighted moving averages to account for any potential benefits of one calculation method over another. RESULTS: Although there were some significant differences between coupled and uncoupled chronic TL and ACWR data, the effect sizes of these differences were almost all trivial (g = 0.04-0.21). Correlations ranged from r = .55 to .76, .17 to .53, and .88 to .99 for acute to chronic TL, acute to uncoupled chronic TL, and ACWR to uncoupled ACWR, respectively. CONCLUSIONS: There may be low risk of mathematical coupling causing spurious correlations in the TL-injury-risk relationship. Varying levels of correlation seem to exist naturally between acute and chronic TL variables regardless of coupling. The trivial to small effect sizes and large to nearly perfect correlations between coupled and uncoupled AWCRs also imply that mathematical coupling may have little effect on either calculation method, if practitioners choose to apply the ACWR for TL monitoring purposes.

Detecting automation failures in a simulated supervisory control environment.

The goal of this research was to determine how individuals perform and allocate their visual attention when monitoring multiple automated displays that differ in automation reliability. Ninety-six participants completed a simulated supervisory control task where each automated display had a different level of reliability (namely 70%, 85% and 95%). In addition, participants completed a high and low workload condition. The performance data revealed that (1) participants' failed to detect automation misses approximately 2.5 times more than automation false alarms, (2) participants' had worse automation failure detection in the high workload condition and (3) participant automation failure detection remained mostly static across reliability. The eye tracking data revealed that participants spread their attention relatively equally across all three of the automated displays for the duration of the experiment. Together, these data support a system-wide trust approach as the default position of an individual monitoring multiple automated displays. Practitioner Summary: Given the rapid growth of automation throughout the workforce, there is an immediate need to better understand how humans monitor multiple automated displays concurrently. The data in this experiment support a system-wide trust approach as the default position of an individual monitoring multiple automated displays. Abbreviations: DoD: Department of Defense; UA: unmanned aircraft; SCOUT: Supervisory Control Operations User Testbed; UAV: unmanned aerial vehicle; AOI: areas of interest.

The Current State of Subjective Training Load Monitoring-a Practical Perspective and Call to Action.

This commentary delivers a practical perspective on the current state of subjective training load (TL) monitoring, and in particular sessional ratings of perceived exertion, for performance enhancement and injury prevention. Subjective measures may be able to reflect mental fatigue, effort, stress, and motivation. These factors appear to be important moderators of the relationship TL has with performance and injury, and they also seem to differ between open and closed skill sports. As such, mental factors may affect the interaction between TL, performance, and injury in different sports. Further, modeling these interactions may be limited due to the assumption that an independent signal can adequately account for the performance or injury outcomes. An independent signal model does not accurately reflect training environments where multiple stressors (e.g., mechanical, emotional, nutritional) impact adaptations. Common issues with using subjective TL monitoring, including a lack of differentiation between biomechanical, physiological, and cognitive load, may be overcome by considering psychometric measurement best practices, finer graded scales, and differential ratings of perceived exertion. Methods of calculating TL, including different acute and chronic time periods, may also need to be individualized to different sports and potentially different individuals within the same sport. As TL monitoring is predominately a "chronic" decision-making tool, "acute" decision-making tools, e.g., subjective wellness and autonomic nervous system measures, should be combined in a bespoke multivariate model to aid sports coaches. A call to action is presented for future research on key issues associated with TL monitoring that will have relevance for practitioners in an applied setting.

Pupil size as a measure of within-task learning.

Pupillometry is commonly used in research to determine how much mental effort an individual is exerting while completing tasks. Traditionally, larger pupils are associated with increased mental effort when completing more difficult tasks. However, little research has investigated how pupils change as individuals learn a new task. In theory, as one repeatedly completes a task, the task demands should reduce, reliance on working memory should decrease, and the task should become more automatic. This should translate to faster completion times and smaller peak pupil dilations. We tested this hypothesis by having participants complete multiple trials of a cognitive task that requires individuals to orient themselves in space relative to a target. We found that trial completion times and maximum pupil size significantly reduced across trials. These data suggest that measuring changes in pupil dilation may help researchers determine whether individuals have shifted from a learned procedure to an automatic processing of information when learning a new task.

Maximal Strength Training Improves Surfboard Sprint and Endurance Paddling Performance in Competitive and Recreational Surfers.

Coyne, JOC, Tran, TT, Secomb, JL, Lundgren, LE, Farley, ORL, Newton, RU, and Sheppard, JM. Maximal strength training improves surfboard sprint and endurance paddling performance in competitive and recreational surfers. J Strength Cond Res 31(1): 244-253, 2017-Upper-body (UB) strength has very high correlations with faster surfboard paddling speeds. However, there is no research examining the effects of improving UB strength has on surfboard paddling ability. This study aimed to determine the influence that improvements in UB closed-kinetic chain maximal strength have on surfboard paddling in both competitive and recreational surfers. Seventeen competitive and recreational male surfers (29.7 ± 7.7 years, 177.4 ± 7.4 cm, 76.7 ± 9.9 kg) participated in a repeated-measures, parallel control study design. Anthropometry; 5-, 10-, and 15-m sprint; and 400-m endurance surfboard paddling tests along with pull-up and dip 1 repetition maximum strength tests were assessed pre- and postintervention. Subjects in the training group performed 5 weeks of maximal strength training in the pull-up and dip. Differences between the training and control groups were examined postintervention. The training group increased their speed over the 5-, 10-, and 15-m sprint, whereas the control group became slower (d = 0.71, 0.51, and 0.4, respectively). The training group also displayed faster endurance paddling performance compared with the control group (d = 0.72). Short-term exposure to maximal strength training elicits improvements in paddling performance measures. However, the magnitude of performance increases seems to be dependent on initial strength levels with differential responses between strong and weaker athletes. Although a longer maximal strength training period may have produced more significant paddling improvements in stronger subjects, practitioners are unlikely to have any more than 5 weeks in an uninterrupted block with competitive surfing athletes. This study reveals that a "threshold" level of maximal strength that if possessed, short-term maximal strength training may only provide little improvement in paddling performance.