Showing the limitations of available phenotypic assays to detect Burkholderia pseudomallei from clinical specimens in Nigeria.

The genus Burkholderia comprises Gram-negative bacteria that are metabolically complex and versatile, often thriving in hostile settings. Burkholderia pseudomallei , the causative agent of melioidosis, is a prominent member of the genus and a clinical pathogen in tropical and sub-tropical regions. This pathogen is well known for its multidrug resistance and possible bioweapon potential. There is currently no report of the pathogen from clinical specimens in Nigeria, which might be due to misdiagnosis with phenotypic assays. This study aims to explore the accuracy of the use of phenotypic assays to diagnose B. pseudomallei in Nigeria. Two hundred and seventeen clinical samples and 28 Gram-negative clinical isolates were collected and analysed using Ashdown's selective agar and monoclonal antibody-based latex agglutination. Species-level identification was achieved using the analytical profile index (API) 20NE system. The susceptibility of the isolates to nine different antimicrobial agents was determined using the disc diffusion method. A total of seventy-four culture-positive isolates were obtained using Ashdown's selective agar. Twenty-two of these isolates were believed to be B. pseudomallei through the monoclonal antibody-based latex agglutination test and the API 20NE system subsequently identified 14 isolates as Burkholderia . The predominant Burkholderia species was B. cepacia with an isolation rate of 30.8 % (8/26). No isolate was distinctively identified as B. pseudomallei but five isolates were strongly suspected to be B. pseudomallei with similarity indices ranging from 81.9-91.3 %. Other bacterial species with definitive identity include Aeromonas sp., Sphingomonas sp. and Pseudomonas aeruginosa . The antibiotic susceptibility results revealed an overall resistance to amoxicillin-clavullanic acid of 71.4 %, to cefepime of 33.3 %, to trimethoprim-sulfamethoxazole of 38.1 %, to piperacillin-tazobactam of 33.3 %, to imipenem of 66.7 %, to doxycycline of 57.1% and to ceftazidime of 66.7 %. The highest intermediate resistance was observed for cefepime and piperacillin-tazobactam with a value of 66.7 % each, while there was no intermediate resistance for gentamicin, colistin and imipenem. Our findings, therefore, show that phenotypic assays alone are not sufficient in the diagnosis of melioidosis. Additionally, they provide robust support for present and future decisions to expand diagnostic capability for melioidosis beyond phenotypic assays in low-resource settings.

Blood analytes of clinically normal and diseased neonatal and weaned farmed white-tailed deer (Odocoileus virginianus) fawns.

Recent research focused on farmed deer has exposed many knowledge gaps regarding health assessment protocols for white-tailed deer (WTD). The objectives of this study were to establish de novo blood analyte reference intervals for farmed WTD fawns at birth (1-2 days of age; n = 84) and again at weaning (76-125 days of age; n = 28), to compare data at birth and at weaning to understand how these analytes are affected by the intrinsic factors age and sex in clinically normal WTD fawns, and to compare between clinically normal and sick WTD weanlings (respiratory disease n = 12; orbivirus-infected n = 6). Reference intervals were established for WTD fawns at birth and weaning. Female WTD neonates had significantly higher red blood cell counts, hematocrit, and hemoglobin compared to males. Most blood analytes were significantly different in clinically normal WTD neonates compared to weanlings, suggesting an effect of age. The observed sex- and age-related variations in WTD highlight the need to establish reference intervals that account for intrinsic factors. The comparison of clinically normal and sick WTD weanlings in this study identified higher MCHC and absolute monocytes in sick weanlings but these findings were presumably not biologically relevant given the small sample size for sick fawns. While the reference interval data presented herein will be useful for the veterinary care of WTD fawns at critical time periods in a high-density farm setting, this study also demonstrates the need to identify more sensitive and specific biomarkers for the assessment of health status in farmed WTD with specific underlying diseases.

Clinical and microbiological profile of otomycosis in Lagos, Nigeria.

Introduction: Otomycosis is a global disease, common in the world's tropical and subtropical regions. The diagnosis is clinical, but mycological examination is required for its confirmation. There is a paucity of published data on otomycosis particularly the aetiologic agents in Nigeria. This study aims to fill in this gap by assessing the clinical presentations, risk factors and aetiologic agents of otomycosis in our setting. Methods: This was a prospective study of 126 clinically diagnosed patients and 30 controls. Mycological analysis of debris and swab samples from their external auditory canal was carried out. Results: One hundred and twenty-six patients were recruited, with 162 ear samples collected. There was mycological confirmation of otomycosis in 100 (79.4%) patients (subjects) and 127 (78.4%) specimens. The subjects' age range was 1-80 years, 30.89 ± 21.15 mean age, and 29-year median age. The peak prevalent age of 1-10 years was statistically significant, P = 0.022. The common symptoms in the subjects were itching 86 (86%), ear blockage 84 (84%) and otalgia 73 (73%). Regular ear cleaning 67 (67.0%) was the most common risk factor. Noted aetiologic agents were Aspergillus species 81 (63.8%), Candida species 42 (33.1%) and Yeast 4 (3.1%). Aspergillus flavus (40/127; 31.5%) was the most common fungus isolated. Unilateral otomycosis 73 (73%) was more common than bilateral otomycosis 27 (27%). Conclusion: Otomycosis is common in all ages, and is a commonly unilateral disease. Regular ear cleaning is the most common risk factor. A. flavus was the most common aetiologic agent in this study.

Presence of Burkholderia pseudomallei in Soil, Nigeria, 2019.

Melioidosis, caused by the soil-dwelling bacterium Burkholderia pseudomallei, is predicted to be endemic in Nigeria but is only occasionally reported. This report documents the systematic identification of the presence of B. pseudomallei and B. thailandensis in the soil across multiple states in Nigeria.

RePP Africa - a georeferenced and curated database on existing and proposed wind, solar, and hydropower plants.

Promoting a transition to low-carbon energy systems to mitigate climate change requires an optimization of renewable energy (RE) planning. However, curated data for the most promising RE technologies, hydro-, wind and solar power, are missing, which limits data-based decision-making support. Here, a spatially explicit database for existing and proposed renewable power plants is provided: The Renewable Power Plant database for Africa (RePP Africa) encompasses 1074 hydro-, 1128 solar, and 276 wind power plant records. For each power plant, geographic coordinates, country, construction status, and capacity (in megawatt) are reported. The number of RePP Africa records exceeds the respective values in other existing open-access databases and matches available cumulative capacity data reported by international energy organizations best with deviations <13% for hydro-, <23% for wind, and <32% for solar power plants. This contemporary database is the most harmonized open-accessible reference source on RE power plants across Africa for stakeholders from science, (non-)governmental organizations, consulting, and industry; providing a fundamental data basis for the development of an integrated sustainable RE mix.

Irreversible Loss of HIV-1 Proviral Competence in Myeloid Cells upon Suppression of NF-κB Activity.

Although antiretroviral therapy (ART) sustains potent suppression of plasma viremia in people with HIV-1 infection (PWH), reservoirs of viral persistence rekindle viral replication and viremia if ART is halted. Understanding the nature of viral reservoirs and their persistence mechanisms remains fundamental to further research aiming to eliminate them and achieve ART-free viral remission or virological cure. CD4+ T-cell models have helped to define the mechanisms that regulate HIV-1 latency as well as to identify potential latency manipulators, and we similarly hoped to extend this understanding to macrophages given the increasing evidence of a role for myeloid cells in HIV-1 persistence under ART (T. Igarashi, C. R. Brown, Y. Endo, A. Buckler-White, et al., Proc Natl Acad Sci U S A 98:658-663, 2001, https://doi.org/10.1073/pnas.98.2.658; J. M. Orenstein, C. Fox, and S. M. Wahl, Science 276:1857-1861, 1997, https://doi.org/10.1126/science.276.5320.1857). In the pursuit of a primary cell model of macrophage latency using monocyte-derived macrophages (MDMs), we observed that NF-κB inhibition, originally intended to promote synchronous entry into a latent state, led to an irreversible loss of proviral competence. Proviruses were refractory to latency reversal agents (LRAs), yet host cell functions such as phagocytic capacity and cytokine production remained intact. Even after NF-κB inhibition was relieved and NF-κB action was restored, proviruses remained refractory to reactivation. Agents that interfere with the NF-κB-HIV-1 axis in myeloid cells may provide an approach with which to render myeloid cell reservoirs inert. IMPORTANCE Although HIV-1 infection can be suppressed using antiretroviral therapy, it cannot yet be cured. This is because HIV-1 integrates itself into host cells and may become dormant but also remains ready to emerge from such reservoirs when antiretroviral therapy stops. The CD4+ T cell has been the most actively investigated cell type in reservoir research due to its prominent role in hosting HIV-1; however, HIV-1 can infect and fall latent in myeloid cells, and therefore, their role must also be assessed in pursuit of a cure. Here, we show that caffeic acid and resveratrol, two nontoxic chemicals, both of which interfere with the same set of host mechanisms, can each prevent HIV-1 reactivation from latency in myeloid cells even after either chemical is removed and previous cell functionality is restored. Strategies to interfere with latency underlie the future of HIV-1 cure research, and our findings help to focus such strategies on an important but often neglected cell type.

Enabling successful transition-Evaluation of a transition to adult care program for pediatric liver transplant recipients.

BACKGROUND: This study aimed to evaluate the transition to adult care program instituted for liver transplant recipients (LTRs) at a large tertiary pediatric hospital in Melbourne, Australia. Evaluation included the change in a Global Assessment Measure (GAM) before and after the transition program, satisfaction with the program, and measures of transition success including rejection rates and attendance at appointments post-transfer. We hypothesized that the introduction of our structured transition program would improve disease understanding, health system understanding, and self-care. We also hypothesized that those who had undergone the transition program would have lower failure to attend rates and lower rates of rejection than historical controls. METHODS: A LTR transition program was instituted at our service from 2013 to 2015. The program involved initial assessment of competencies with a Global Assessment Measure (GAM), followed by the introduction of a personalized goal setting program addressing issues identified in dedicated transition clinics. Assessment of competencies was compared between the commencement of the program and immediately prior to transfer. Patient satisfaction with the transition process was assessed at an interview 6-12 months after transfer to the adult service. Rejection rates and failure to attend rates were compared between the intervention group and a group of LTRs who did not receive the intervention. RESULTS: Twenty-eight LTRs participated in the study; 20 received the transition intervention and 8 served as controls. Within the intervention group, all domains of transition competency and reported anxiety regarding transferring had significantly improved at the conclusion of the intervention and all reported satisfaction with the transition program with most (81%) reporting readiness to transfer. There were no significant differences in rejection rates or failure to attend rates between those who did and did not receive the transition intervention. CONCLUSION: A longitudinal holistic transition program has the potential to positively impact the competencies and readiness of LTRs to successful transition and transfer to adult care.

Adding a Seat at the Table: A Case Study of the Provider's Perspective on Integrating Community Health Workers at Provider Practices in California.

Blue Shield of California's Community Health Advocate Program was created to support whole person-health needs by helping individuals of all socio-economic statuses navigate and access community resources, social services, and medical systems. Blue Shield's Health Reimagined team is partnering with medical providers, community resources centers, and community partners to provide intensive person-centered and technology-enabled care to patients, ensuring social needs are met while promoting health equity. A key aspect of the Health Reimagined initiative embeds Community Health Advocates (CHAs) within physician practices serving patients using a payor-agnostic approach, by which Blue Shield aims to increase access to social services and community resources, improve health outcomes, reduce medical costs, and improve overall patient experience. The purpose of this case study is to understand the provider's perspective of embedding a CHA into the care team and the resulting impact on the practice and patients. Blue Shield also sought to identify best practices and barriers of a CHA program within primary and specialty care practices. As part of an ongoing two-year mixed-methods impact evaluation (2019-2021), 10 semi-structured interviews were conducted with a total of 18 providers and office staff at five primary care and specialty practices where CHAs have been embedded. We also conducted two focus groups with the same five CHAs at different points in time. Several themes emerged from the provider, office staff, and CHA interviews. Provider practices found great value in adding a CHA to their care team as the CHA brings flexibility and continuity to patient care. They also found that having access to a CHA with shared life experiences of the communities they served is a key component to the program's success. Providers and staff reported a new understanding of the social determinants of health that impacts a patient's wellbeing with the embedding of a CHA in the care team. Overall, practitioners expressed high satisfaction with the CHA program. During the COVID-19 pandemic, CHAs have been critically important in care, as social needs have increased, and resources have shifted. The CHA program is constantly adapting to address challenges faced by all stakeholders and applying new knowledge to ensure best practices are implemented within the CHA program.

Resource Selection by Wild and Ranched White-Tailed Deer (Odocoileus virginianus) during the Epizootic Hemorrhagic Disease Virus (EHDV) Transmission Season in Florida.

Epizootic hemorrhagic disease virus (EHDV) causes serious disease in wild and privately ranched white-tailed deer (Odocoileus virginianus) in the United States. In Florida, there is high EHDV prevalence, yet no treatments. There are few management strategies for the disease due to limited knowledge of virus-vector-host interactions. We conducted a telemetry study on white-tailed deer to examine resource use by wild and ranched animals in the Florida panhandle during the 2016 transmission risk period. We built generalized linear mixed models (GLMMs) to estimate resource selection and map habitat preferences for wild and ranched deer in the study area to reveal how second-order selection may relate to higher disease prevalence in ranched deer. Wild deer preferred areas closer to tertiary roads and supplementary food sources but farther from permanent water. Ranched deer selected bottomland mixed forest and areas closer to tertiary roads, supplementary food sources, and permanent water. Ranched deer behaviors may increase the likelihood of EHDV vector encounters, as these deer selected preferred habitats of several putative vector species, which may increase vector blood meal success and viral transmission risk. Disparate resource selection behaviors may be a factor in observed differential EHDV exposure risk between ranched and wild white-tailed deer in Florida.

The Human Phenotype Ontology in 2021.

The Human Phenotype Ontology (HPO, https://hpo.jax.org) was launched in 2008 to provide a comprehensive logical standard to describe and computationally analyze phenotypic abnormalities found in human disease. The HPO is now a worldwide standard for phenotype exchange. The HPO has grown steadily since its inception due to considerable contributions from clinical experts and researchers from a diverse range of disciplines. Here, we present recent major extensions of the HPO for neurology, nephrology, immunology, pulmonology, newborn screening, and other areas. For example, the seizure subontology now reflects the International League Against Epilepsy (ILAE) guidelines and these enhancements have already shown clinical validity. We present new efforts to harmonize computational definitions of phenotypic abnormalities across the HPO and multiple phenotype ontologies used for animal models of disease. These efforts will benefit software such as Exomiser by improving the accuracy and scope of cross-species phenotype matching. The computational modeling strategy used by the HPO to define disease entities and phenotypic features and distinguish between them is explained in detail.We also report on recent efforts to translate the HPO into indigenous languages. Finally, we summarize recent advances in the use of HPO in electronic health record systems.

Effects of climate change on coastal ecosystem food webs: Implications for aquaculture.

Coastal ecosystems provide important ecosystem services for millions of people. Climate change is modifying coastal ecosystem food web structure and function and threatens these essential ecosystem services. We used a combination of two new and one existing ecosystem food web models and altered scenarios that are possible with climate change to quantify the impacts of climate change on ecosystem stability in three coastal bays in Maine, United States. We also examined the impact of climate change on bivalve fisheries and aquaculture. Our modeled scenarios explicitly considered the predicted effects of future climatic change and human intervention and included: 1) the influence of increased terrestrial dissolved organic carbon loading on phytoplankton biomass; 2) benthic community change driven by synergisms between climate change, historical overfishing, and increased species invasion; and 3) altered trophic level energy transfer driven by ocean warming and acidification. The effects of climate change strongly negatively influenced ecosystem energy flow and ecosystem stability and negatively affected modeled bivalve carrying capacity in each of our models along the Maine coast of the eastern United States. Our results suggest that the interconnected nature of ecosystem food webs make them extremely vulnerable to synergistic effects of climate change. To better inform fisheries and aquaculture management, the effects of climate change must be explicitly incorporated.

Epizootic Hemorrhagic Disease Virus and Bluetongue Virus Seroprevalence in Wild White-Tailed Deer (Odocoileus virginianus) in Florida, USA.

A wild population of white-tailed deer (Odocoileus virginianus) was surveyed for evidence of past or current epizootic hemorrhagic disease virus (EHDV) and current bluetongue virus (BTV) infections. We collected 121 blood samples from hunter-harvested or live-captured deer from two state-managed properties in northwest Florida, US; live captures were in support of a movement ecology study. Blood samples were tested for antibodies against titers to three EHDV serotypes (EHDV-1, EHDV-2, and EHDV-6), and multiplex quantitative reverse transcription PCR was used to identify the presence of EHDV or BTV viral RNA. Of these samples, 81% (98/121) tested seropositive for at least one of three serotypes of EHDV. Of those testing seropositive, 33% (40/121) contained antibodies for two serotypes, and 19% (24/121) contained antibodies for all three EHDV serotypes. Furthermore, results of generalized linear models indicated that the probability of infection by EHDV serotypes 1 and 6 increased with an animal's age. Our findings indicate that seroprevalence may be high for multiple serotypes in regions where these orbiviruses are endemic. These results could prove useful for managing disease risk in naïve deer populations.

Refusing the Development NGO? Departure, Dismissal, and Misrecognition in Angolan Development Interventions.

Nongovernmental organizations working in international development increasingly follow a neoliberalized management model, hiring professional employees to conduct the work of social transformation under a bureaucratic regime that sees the recruitment and retention of staff members as rational transactions between employer and employee. Such managerialist thinking holds that staff members represent bundles of skills and knowledge to be sorted and allocated according to the requirements of work, that they seek to exchange their labor for payment, and that they may justifiably be fired for misdeeds like misuse of materials, misrepresenting themselves, or poor work quality, as determined by the institution. I use the example of local staff members resigning and being fired from an international democratization intervention in postwar Angola to argue that some development professionals refuse to occupy such management-defined subject positions, asserting instead their independent moralities about the place of implementation staff in international development work. International development institutions misrecognize many such acts, however, leaving intact unequal relations of power within the very industry meant to combat such unequal relations on a global scale.

RSVpredict: An Online Tool to Calculate the Likelihood of Respiratory Syncytial Virus Infection in Children Hospitalized With Acute Respiratory Disease.

BACKGROUND: Respiratory syncytial virus (RSV) is the leading cause of acute lower respiratory tract infection in young children. Early detection of RSV infection can avoid unnecessary diagnostic and therapeutic intervention and is required to prevent the nosocomial spread of RSV infection in pediatric hospitals. We developed a web tool to calculate the probability of RSV infection in children hospitalized with acute respiratory tract infection (ARTI) (RSVpredict). METHODS: During winter seasons 2014/2015 to 2017/2018, 1545 children hospitalized with clinical symptoms of ARTI at the University Hospital Heidelberg/Germany were prospectively included. Medical information was reported on a standardized data sheet, and nasopharyngeal swabs were obtained for multiplex real-time polymerase chain reaction analyses. We applied logistic regression to develop a prediction model and developed a web-based application to predict the individual probability of RSV infection. RESULTS: Duration of clinical symptoms ≥2 days on admission, calendar month of admission, admission for lower respiratory tract infection, the presence of cough and rale and younger age were associated with RSV infection (P < 0.05). Those data were included in the prediction model (RSVpredict, https://web.imbi.uni-heidelberg.de/rsv/). RSVpredict is a web-based application to calculate the risk of RSV infection in children hospitalized with ARTI. The prediction model is based on easily accessible clinical symptoms and predicts the individual probability of RSV infection risk immediately. CONCLUSIONS: Pediatricians might use the RSVpredict to take informed decisions on further diagnostic and therapeutic intervention, including targeted RSV testing in children with relevant RSV infection risk.

Traversing the liminal: what can Fontan adults' transition experiences and perspectives teach us about optimizing healthcare?

BACKGROUND: Successfully transitioning to adult care is important for congenital heart disease (CHD) patients, particularly those at the worst end of the spectrum with a Fontan circulation, as their ongoing health engagement affects their health outcomes. Yet, there is a lack of literature exploring patient perspectives about their transition experiences, and what helps or hinders successful transition to adult care. METHODS: Young adults with a Fontan circulation (n = 18) from the Australian and New Zealand Fontan Registry participated in in-depth phone interviews. Thematic analyses were used to analyze the qualitative interview data. RESULTS: We identified six key themes which stood out from patient experiences, including differences between pediatric and adult congenital cardiac care, the need for preparation through formal transition programs, and the important role of support systems. CONCLUSION: To become active managers of their healthcare and remain engaged with the healthcare system, young people would benefit from coordinated efforts between pediatric and adult care to formally prepare them for transition to adult care. This should include involvement from their support network and ongoing education about their health condition. The study highlights the importance of studying patient perspectives through qualitative research to better inform health service provision in the CHD space.

"Will she live a long happy life?" Parents' concerns for their children with Fontan circulation.

BACKGROUND: Families of children at the worst end of the congenital heart disease endure a significant burden which is often not clearly delineated in the clinical literature. We examined the greatest concerns of parents whose children have a Fontan circulation. METHODS: Parents (N = 107) of children in the Australian and New Zealand Fontan Registry completed online surveys with open-ended and closed questions. A qualitative method approach incorporating thematic analyses was used. RESULTS: The greatest concerns for parents of a child with a Fontan circulation were centered on fear of death for their child and psychosocial well-being, followed by lesser themes around anti-coagulation use, pregnancy and financial burdens. CONCLUSIONS: Fear of death and the psychological well-being of their children were the main parental concerns. It highlights the need to clearly communicate information on outcomes to families, and the need for family-focused psychological interventions to improve the psychosocial functioning of both parents and young people.

"How long will I continue to be normal?" Adults with a Fontan circulation's greatest concerns.

BACKGROUND: Little is known about adults living with a Fontan circulation's concerns outside the scope of their clinical outcomes. We examined adults with a Fontan circulations' greatest concerns, as well as their concerns around anti-coagulation, pregnancy and finances. METHODS: Adults with a Fontan circulation in the Australian and New Zealand Fontan Registry were invited to complete an anonymous online survey, of which 57 participated. A qualitative method approach using thematic analyses was used. RESULTS: The greatest concerns for adults living with a Fontan circulation were fear of death/uncertainty around life expectancy which for many individuals colored their concerns around physical health, pregnancy and having children, quality of life and finances. Improving information about outcomes to patients with a Fontan circulation might alleviate uncertainties about their future. CONCLUSIONS: Fear of death is the primary concern of adults with a Fontan circulation. It may require improved communication and targeted psychological interventions. Physical exercise incorporated as part of their lifestyle should be encouraged to alleviate physical concerns and also improve psychological well-being.

Restoring water quality in the polluted Turag-Tongi-Balu river system, Dhaka: Modelling nutrient and total coliform intervention strategies.

River water quality in rapidly urbanising Asian cities threatens to damage the resource base on which human health, economic growth and poverty reduction all depend. Dhaka reflects the challenges and opportunities for balancing these dynamic and complex trade-offs which goals can be achieved through effective policy interventions. There is a serious problem of water pollution in central Dhaka, in the Turag-Tongi-Balu River system in Bangladesh with the river system being one of the most polluted in the world at the moment. A baseline survey of water chemistry and total coliforms has been undertaken and shows dissolved oxygen close to zero in the dry season, high organic loading together with extreme levels of Ammonium-N and total coliform in the water. Models have been applied to assess hydrochemical processes in the river and evaluate alternative strategies for policy and the management of the pollution issues. In particular models of flow, Nitrate-N, Ammonium-N and indicator bacteria (total coliforms) are applied to simulate water quality in the river system. Various scenarios are explored to clean up the river system, including flow augmentation and improved effluent treatment. The model results indicate that improved effluent treatment is likely to have a more significant impact on reducing Ammonium-N and total coliforms than flow augmentation, but a combined strategy would greatly reduce the pollution problems in the Turag-Tongi-Balu River System.

Characteristics of Patient-Centered Medical Home Initiatives that Generated Savings for Medicare: a Qualitative Multi-Case Analysis.

BACKGROUND: Through the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration, Medicare, Medicaid, and private payers offered supplemental payments to 849 primary care practices that became patient-centered medical homes (PCMHs) in eight states; practices also received technical assistance and data reports. Average Medicare payments were capped at $10 per beneficiary per month in each state. OBJECTIVE: Since there was variation in the eight participating states' demonstration designs, experiences, and outcomes, we conducted a qualitative multi-case analysis to identify the key factors that differentiated states that were estimated to have generated net savings for Medicare from states that did not. PARTICIPANTS: States' MAPCP Demonstration initiatives were comprehensively profiled in case studies based on secondary document review, three rounds of annual interviews with state staff, payers, practices, and other stakeholders, and other data sources. APPROACH: Case study findings were summarized in a case-ordered predictor-outcome matrix, which identified the presence or absence of key demonstration design features and experiences and arrayed states based on the amount of net savings or losses they generated for Medicare. We then used this matrix to identify initiative features that were present in at least three of the four states that generated net savings and absent from at least three of the four states that did not generate savings. RESULTS: A majority of the states that generated net savings: required practices to be recognized PCMHs to enter the demonstration, did not allow late entrants into the demonstration, used a consistent demonstration payment model across participating payers, and offered practices opportunities to earn performance bonuses. Practices in states that generated net savings also tended to report receiving the demonstration payments and bonuses they expected to receive, without any issues. CONCLUSIONS: Designers of future PCMH initiatives may increase their likelihood of generating net savings by incorporating the demonstration features we identified.

Perspectives on Implementing Quality Improvement Collaboratives Effectively: Qualitative Findings from the CHIPRA Quality Demonstration Grant Program.

BACKGROUND: The most frequently pursued intervention in the $100 million, 18-state Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) quality demonstration (2010-2015) was quality improvement collaboratives, which 12 states offered to more than 300 primary care practices. A study was conducted to identify which aspects of these collaboratives were viewed by organizers and participants as working well and which were not. METHODS: Some 223 interviews were conducted in these states near the end of their collaboratives. Interview notes were coded and analyzed to identify trends. RESULTS: Aspects of collaboratives that interviewees valued were aimed at attracting participation, maintaining engagement, or facilitating learning. To attract participants, interviewees recommended offering maintenance-of-certification credits, aligning content with existing financial incentives, hiring a knowledgeable collaborative organizer of the same medical specialty as participants, and having national experts speak at meetings. Positively viewed approaches for maintaining engagement included meeting one-on-one with practices to articulate participation expectations in advance, tying disbursal of stipends to meeting participation expectations, and soliciting feedback and making mid-course adjustments. To facilitate learning, interviewees liked learning from other practices, interactive exercises, practical handouts, and meeting face-to-face with new referral partners. CONCLUSION: Prior studies have tended to focus on strategies to maintain engagement. The interviewees valued these features but also valued aspects of collaboratives that attracted participants in the first place and facilitated learning after participants were actively engaged. The findings suggest that a wider array of features may be important when developing or evaluating collaboratives. Collaborative organizers may benefit from incorporating the recommended collaborative features into their own collaboratives.