Alternating regimes of shallow and deep-sea diversification explain a species-richness paradox in marine fishes.

The deep sea contains a surprising diversity of life, including iconic fish groups such as anglerfishes and lanternfishes. Still, >65% of marine teleost fish species are restricted to the photic zone <200 m, which comprises less than 10% of the ocean's total volume. From a macroevolutionary perspective, this paradox may be explained by three hypotheses: 1) shallow water lineages have had more time to diversify than deep-sea lineages, 2) shallow water lineages have faster rates of speciation than deep-sea lineages, or 3) shallow-to-deep sea transition rates limit deep-sea richness. Here we use phylogenetic comparative methods to test among these three non-mutually exclusive hypotheses. While we found support for all hypotheses, the disparity in species richness is better described as the uneven outcome of alternating phases that favored shallow or deep diversification over the past 200 million y. Shallow marine teleosts became incredibly diverse 100 million y ago during a period of warm temperatures and high sea level, suggesting the importance of reefs and epicontinental settings. Conversely, deep-sea colonization and speciation was favored during brief episodes when cooling temperatures increased the efficiency of the ocean's carbon pump. Finally, time-variable ecological filters limited shallow-to-deep colonization for much of teleost history, which helped maintain higher shallow richness. A pelagic lifestyle and large jaws were associated with early deep-sea colonists, while a demersal lifestyle and a tapered body plan were typical of later colonists. Therefore, we also suggest that some hallmark characteristics of deep-sea fishes evolved prior to colonizing the deep sea.

The rise of biting during the Cenozoic fueled reef fish body shape diversification.

Diversity of feeding mechanisms is a hallmark of reef fishes, but the history of this variation is not fully understood. Here, we explore the emergence and proliferation of a biting mode of feeding, which enables fishes to feed on attached benthic prey. We find that feeding modes other than suction, including biting, ram biting, and an intermediate group that uses both biting and suction, were nearly absent among the lineages of teleost fishes inhabiting reefs prior to the end-Cretaceous mass extinction, but benthic biting has rapidly increased in frequency since then, accounting for about 40% of reef species today. Further, we measured the impact of feeding mode on body shape diversification in reef fishes. We fit a model of multivariate character evolution to a dataset comprising three-dimensional body shape of 1,530 species of teleost reef fishes across 111 families. Dedicated biters have accumulated over half of the body shape variation that suction feeders have in just 18% of the evolutionary time by evolving body shape ∼1.7 times faster than suction feeders. As a possible response to the ecological and functional diversity of attached prey, biters have dynamically evolved both into shapes that resemble suction feeders as well as novel body forms characterized by lateral compression and small jaws. The ascendance of species that use biting mechanisms to feed on attached prey reshaped modern reef fish assemblages and has been a major contributor to their ecological and phenotypic diversification.

Dose Changes for Long-term Opioid Patients Following a State Opioid Prescribing Policy.

BACKGROUND: In 2018, Nevada implemented opioid prescribing legislation (AB474) to support the uptake of CDC pain care guidelines. We studied the law's association with doses over threshold levels of morphine milligram equivalents (MMEs) and with time to dose increases and decreases, among long-term opioid patients. METHODS: A difference-in-difference study examined dosing changes across opioid prescription episodes (ie, prescriptions within 30 day and within the same dosing threshold). Patients with at least 120 days supply over 6 months in Nevada and Colorado Medicaid pharmacy claims were included. Using a logistic regression model, we compare the predicted probabilities that opioid episodes exceeded 50 MME before and after implementation of the law, in both states. Adjusted hazard ratios (aHR) from a gap time survival model estimated time to escalate above 50 MME among low-dose episodes (<50 MME), and time to de-escalate below 50 MME among high-dose episodes (≥50 MME). RESULTS: Among 453,577 episodes (74,292 patients), the Nevada law was associated with a 2.9% reduction in prescriptions over 50 MME (95% CI: -3.5, -2.3) compared with Colorado. While the law was also associated with slower escalation (Nevada: aHR = 0.75; 95% CI: 0.72, 0.77, Colorado: aHR = 1.04; 95% CI: 1.01, 1.06), it was also associated with slower de-escalation (Nevada: aHR = 0.87; 95% CI: 0.84, 0.89, Colorado: aHR = 0.97; 95% CI: 0.96, 0.99). CONCLUSIONS: Slower dose escalations, rather than faster dose de-escalation, likely explain post-law reductions in doses over 50 MME. Slower dose de-escalations may be due to longer days supply post-policy.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial.

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

A cohort-based nutrition ECHO for community health workers.

Project Extension for Community Healthcare Outcomes (ECHO) Nevada applied the ECHO virtual hub-and-spoke telementoring model over nine 6-week cohorts (between November 2019 and November 2021) supporting community health workers (CHWs) who advise clients with diabetes or pre-diabetes. This study describes the program implementation, including evaluation data collection efforts. Didactic topics included 'Intro to Healthy Eating and Easy Wins' to 'Grocery Shopping, Cooking Tips, Reading Labels, Meal Plans' and 'Reducing Bias and Being a Good Role Model'. Spoke participants signed up to review cases. Seventy-three of the enrolled participants (n = 100) attended three or more of the six sessions. Spoke participants completed 42 case presentations. The average self-efficacy increased from 2.7 [standard deviation (SD): 1.1] before completing the program to 4.1 (SD: 0.8) after completing the program. Average knowledge scores increased from 71 (SD: 16) before completing the program to 83 (SD: 14) after completing the program. Five group interviews drew actionable feedback that was incorporated into the program. Key elements of the ECHO model were successfully incorporated to support educational goals of a cohort of CHWs in nutritional coaching. Our program evaluation data tracking system shows non-significant but encouraging results regarding self-efficacy improvement and knowledge retention.

Analysis of Direct-To-Consumer Healthcare Service Advertisements on Television: An Application of the Patient Expectation Framework.

Direct-to-consumer advertisements for healthcare services constitute a rare channel of public communication where consumers see and hear directly from their local providers and healthcare organizations. Although spending on these advertisements has increased drastically during the past decades, research on their content and effects remains rare. To fill this gap, we analyzed primetime television advertisements for healthcare services directly targeting consumers. The advertisements were collected from the two largest media markets in Nevada for one month. In total, 795 advertisements were identified, and 106 of them were non-duplicates. Analysis revealed that the advertisements focused on patients' good health outcomes by showing them smiling, going out and about, having fun with others, and enjoying rigorous physical activities. On the other hand, the advertisements focused less on the providers. Although the advertisements often showed providers in clinical settings, basic information about their professional degrees was often missing. Mentions of providers' other qualifications and professional experiences were even scarcer. Also, a substantial number of advertisements failed to show providers interacting with patients. Additional analysis of patient and provider characteristics revealed under-representation of racial or ethnic minority and older adult patients. Representation of women and minorities as providers was even more uncommon. We discussed the implications of these findings from the perspective of patient expectation and made suggestions to help providers improve their direct-to-consumer advertisements.

Comparing Gold-standard Copayment and Coinsurance Values From Claims Processing Engines to Values Derived From Behavioral Health Claims Databases.

BACKGROUND: While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate. OBJECTIVE: To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data. SUBJECTS: Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO). MEASURES: Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures). STUDY DESIGN: We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared. PRINCIPAL FINDINGS: Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance. CONCLUSIONS: For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis.

Gynecologist Supply Deserts Across the VA and in the Community.

BACKGROUND: The Veterans Health Administration (VA) refers patients to community providers for specialty services not available on-site. However, community-level specialist shortages may impede access to care. OBJECTIVE: Compare gynecologist supply in veterans' county of residence versus at their VA site. DESIGN: We identified women veteran VA patients from fiscal year (FY) 2017 administrative data and assessed availability of a VA gynecologist within 50 miles (hereafter called "local") of veterans' VA homesites (per national VA organizational survey data). For the same cohort, we then assessed community-level gynecologist availability; counties with < 2 gynecologists/10,000 women (per the Area Health Resource File) were "inadequate-supply" counties. We examined the proportion of women veterans with local VA gynecologist availability in counties with inadequate versus adequate gynecologist supply, stratified by individual and VA homesite characteristics. Chi-square tests assessed statistical differences. PARTICIPANTS: All women veteran FY2017 VA primary care users nationally. MAIN MEASURES: Availability of a VA gynecologist within 50 miles of a veteran's VA homesite; county-level "inadequate-supply" of gynecologists. KEY RESULTS: Among 407,482 women, 9% were in gynecologist supply deserts (i.e., lacking local VA gynecologist and living in an inadequate-supply county). The sub-populations with the highest proportions in gynecologist supply deserts were rural residents (24%), those who got their primary care at non-VAMC satellite clinics (13%), those who got their care at a site without a women's clinic (13%), and those with American Indian or Alaska Native (12%), or white (12%) race. Among those in inadequate-supply counties, 59.9% had gynecologists at their local VA; however, 40.1% lacked a local VA gynecologist. CONCLUSIONS: Most veterans living in inadequate-supply counties had local VA gynecology care, reflecting VA's critical role as a safety net provider. However, for those in gynecologist supply deserts, expanded transportation options, modified staffing models, or tele-gynecology hubs may offer solutions to extend VA gynecology capacity.

Secondary Headache Disorders: Approach, Workup, and Special Considerations for Select Populations.

Headache is one of the most common diagnoses in neurology. A thorough understanding of the clinical presentation of secondary headache, which can be life-threatening, is critical. This review provides an overview of the diagnostic approach to a patient with headache, including discussion of "red," "orange," and "green" flags. We emphasize particular scenarios to help tailor the clinical workup to individual circumstances such as in pregnant women, when particular attention must be paid to the effects of blood pressure and hypercoagulability, as well as in older adults, where there is a need for higher suspicion for an intracranial mass lesion or giant cell arteritis. Patients with risk factors for headache secondary to alterations in intracranial pressure, whether elevated (e.g., idiopathic intracranial hypertension) or decreased (e.g., cerebrospinal fluid leak), may require more specific diagnostic testing and treatment. Finally, headache in patients with COVID-19 or long COVID-19 is increasingly recognized and may have multiple etiologies.

The deep sea is a hot spot of fish body shape evolution.

Deep-sea fishes have long captured our imagination with striking adaptations to life in the mysterious abyss, raising the possibility that this cold, dark ocean region may be a key hub for physiological and functional diversification. We explore this idea through an analysis of body shape evolution across ocean depth zones in over 3000 species of marine teleost fishes. We find that the deep ocean contains twice the body shape disparity of shallow waters, driven by elevated rates of evolution in traits associated with locomotion. Deep-sea fishes display more frequent adoption of forms suited to slow and periodic swimming, whereas shallow living species are concentrated around shapes conferring strong, sustained swimming capacity and manoeuvrability. Our results support long-standing impressions of the deep sea as an evolutionary hotspot for fish body shape evolution and highlight that factors like habitat complexity and ecological interactions are potential drivers of this adaptive diversification.

Retaining VA Women's Health Primary Care Providers: Work Setting Matters.

BACKGROUND: When an experienced provider opts to leave a healthcare workforce (attrition), there are significant costs, both direct and indirect. Turnover of healthcare providers is underreported and understudied, despite evidence that it negatively impacts care delivery and negatively impacts working conditions for remaining providers. In the Veterans Affairs (VA) healthcare system, attrition of women's health primary care providers (WH-PCPs) threatens a specially trained workforce; it is unknown what factors contribute to, or protect against, their attrition. OBJECTIVE: Based on evidence that clinic environment, adequate support resources, and workload affect provider burnout and intent to leave, we explored if such clinic characteristics predict attrition of WH-PCPs in the VA, to identify protective factors. DESIGN: This analysis drew on two waves of existing national VA survey data to examine predictors of WH-PCP attrition, via logistic regression. PARTICIPANTS: All 2,259 providers from 140 facilities VA-wide who were WH-PCPs on September 30, 2016. MAIN MEASURES: The dependent variable was WH-PCP attrition in the following year. Candidate predictors were clinic environment (working in: a comprehensive women's health center, a limited women's health clinic, a general primary care clinic, or multiple clinic environments), availability of co-located specialty support resources (mental health, social work, clinical pharmacy), provider characteristics (gender, professional degree), and clinic workload (clinic sessions per week). KEY RESULTS: Working exclusively in a comprehensive women's health center uniquely predicted significantly lower risk of WH-PCP attrition (adjusted odds ratio 0.40; CI 0.19-0.86). CONCLUSIONS: A comprehensive women's health center clinical context may promote retention of this specially trained primary care workforce. Exploring potential mechanisms-e.g., shared mission, appropriate support to meet patients' needs, or a cohesive team environment-may inform broader efforts to retain front-line providers.

Impact of perceived contraceptive policy changes on long acting reversible contraception dispensing trends.

OBJECTIVE: We observed the long-term trend of Long Acting Reversible Contraception (LARC) usage before and after the 2016 presidential election. METHODS: We observed the rate of LARC dispensed at a university student health centre in the 18 months preceding and 27 months following the 2016 U.S. presidential election which posed threat to contraception access. We applied a segmented regression model using two linear regression line segments to evaluate whether there is a time point where the trend of LARC dispensing changed. We fit the regression models with a breakpoint at month 0 (election month) and 3 months with a Locally Estimated Scatterplot Smoothing (LOESS) estimate with parameters obtained by estimating simple linear regression models separately below and above the breakpoint '0'. RESULTS: There were a total of 2067 LARC methods dispensed from May 2015 to February 2019. The average number of LARC methods dispensed before November 2016 was 38/month and increased to 51/month post-presidential election. The LARC dispense rate significantly increased each month (0.38, 1.74; 95% confidence level, p < 0.05) until a breakpoint at 6 months (standard error 4.11) post-election followed by slower decrease (-0.59/month, 95% confidence level: -1.37, 0.20; p=not significant). CONCLUSION: Our study is the first to report long-term trends (27 months post-election) in LARC uptake amidst the public discourse that suggested the end of a policy that provided LARC insurance coverage. Although this observational study cannot suggest causality, the findings could reflect actions taken to prevent unintended pregnancy in response to the event of uncertain national policy.

End-of-life care among adolescent and young adult patients with cancer living in poverty.

BACKGROUND: To the authors' knowledge, end-of-life (EOL) care outcomes among adolescents and young adults (AYAs) with cancer who are living in poverty remain poorly understood. The primary aim of the current study was to examine the effect of poverty on EOL care for AYA patients with cancer. METHODS: The authors conducted a multisite, retrospective study of AYA patients with cancer aged 15 to 39 years who died between January 2013 and December 2016 at 3 academic sites. Medical record-based EOL care outcomes included hospice referral, palliative care (PC) consultation, cancer treatment within the last month of life, and location of death. Two measures of poverty were applied: 1) zip code with a median income ≤200% of the federal poverty level; and 2) public insurance or lack of insurance. Logistic regression analyses were conducted. RESULTS: A total of 252 AYA cancer decedents were identified. Approximately 41% lived in a high-poverty zip code and 48% had public insurance or lacked insurance; approximately 70% had at least 1 poverty indicator. Nearly 40% had a hospice referral, 60% had a PC consultation (76% on an inpatient basis), 38% received EOL cancer treatment, and 39% died in the hospital. In bivariable analyses, AYA patients living in low-income zip codes were found to be less likely to enroll in hospice (P ≤ .01), have an early PC referral (P ≤ .01), or receive EOL cancer treatment (P = .03), although only EOL cancer treatment met statistical significance in multivariable models. No differences with regard to location of death (P = .99) were observed. CONCLUSIONS: AYA patients with cancer experience low rates of hospice referral and high rates of in-hospital death regardless of socioeconomic status. Future studies should evaluate early inpatient PC referrals as a possible method for improving EOL care.

Primitive layered gabbros from fast-spreading lower oceanic crust.

Three-quarters of the oceanic crust formed at fast-spreading ridges is composed of plutonic rocks whose mineral assemblages, textures and compositions record the history of melt transport and crystallization between the mantle and the sea floor. Despite the importance of these rocks, sampling them in situ is extremely challenging owing to the overlying dykes and lavas. This means that models for understanding the formation of the lower crust are based largely on geophysical studies and ancient analogues (ophiolites) that did not form at typical mid-ocean ridges. Here we describe cored intervals of primitive, modally layered gabbroic rocks from the lower plutonic crust formed at a fast-spreading ridge, sampled by the Integrated Ocean Drilling Program at the Hess Deep rift. Centimetre-scale, modally layered rocks, some of which have a strong layering-parallel foliation, confirm a long-held belief that such rocks are a key constituent of the lower oceanic crust formed at fast-spreading ridges. Geochemical analysis of these primitive lower plutonic rocks--in combination with previous geochemical data for shallow-level plutonic rocks, sheeted dykes and lavas--provides the most completely constrained estimate of the bulk composition of fast-spreading oceanic crust so far. Simple crystallization models using this bulk crustal composition as the parental melt accurately predict the bulk composition of both the lavas and the plutonic rocks. However, the recovered plutonic rocks show early crystallization of orthopyroxene, which is not predicted by current models of melt extraction from the mantle and mid-ocean-ridge basalt differentiation. The simplest explanation of this observation is that compositionally diverse melts are extracted from the mantle and partly crystallize before mixing to produce the more homogeneous magmas that erupt.

US direct-to-consumer medical service advertisements fail to provide adequate information on quality and cost of care.

BACKGROUND: In the 1970s, the Federal Trade Commission declared that allowing medical providers to advertise directly to consumers would be "providing the public with truthful information about the price, quality or other aspects of their service." However, our understanding of the advertising content is highly limited. OBJECTIVE: To assess whether direct-to-consumer medical service advertisements provide relevant information on access, quality and cost of care, a content analysis was conducted. METHOD: Television and online advertisements for medical services directly targeting consumers were collected in two major urban centres in Nevada, USA, identifying 313 television advertisements and 200 non-duplicate online advertisements. RESULTS: Both television and online advertisements reliably conveyed information about the services provided and how to make an appointment. At the same time, less than half of the advertisements featured insurance information and hours of operation and less than a quarter of them contained information regarding the quality and price of care. The claims of quality were substantiated in even fewer advertisements. The scarcity of quality and cost information was more severe in television advertisements. CONCLUSION: There is little evidence that medical service advertising, in its current form, would contribute to lower prices or improved quality of care by providing valuable information to consumers.

Urine Drug Testing among Opioid-Naïve and Long-Term Opioid Nevada Medicaid Beneficiaries.

BACKGROUND: Current guidelines recommend that, when prescribing opioids, providers use urine drug testing (UDT) for harm reduction. Objective: To identify whether Medicaid beneficiaries in Nevada at increased risk for opioid misuse received UDT. Methods: We used Nevada Medicaid claims data (2017-2018) to describe UDT among three samples: opioid naïve patients (N = 11,326), opioid naïve patients with a second follow-up prescription (N = 8,910), and long-term opioid patients (N = 19,173). Predictors of opioid misuse include past diagnoses of mental health and substance use, demographic characteristics and potentially risky behaviors. Outcomes include receiving UDT prior to opioid prescription among the two naïve samples and within six months for the long-term sample. We report predicted probabilities (PP) from logistic regressions and hazard ratios (HR) and Kaplan-Meier curves. Results: A small percentage of patients received UDT (naïve sample: 2.5%; naïve with a second follow-up prescription sample: 3.5%; long-term sample: 9.9%). Adults with alcohol disorders and other substance use disorders had the highest PP of UDT, among both the naïve (alcohol related disorder: 3.1%; other substance use disorder: 7.7%) and the naïve with a second follow-up prescription (alcohol related disorder: 4.1%; other substance use disorder: 11.7%) samples. Among the long-term sample, similar predictors were significant. Conclusions: Although there was an association between having risk factors for opioid misuse (e.g. past alchohol disorders and other substance use disorder diagnoses) and receiving UDT, the percentage of patients who received UDT was unexpectedly low, pointing to the need to increase guideline adherence and implementation among providers who prescribe opioids.

The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care.

BACKGROUND: Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment. AIMS OF THE STUDY: Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level. METHODS: A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted. RESULTS: For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services. DISCUSSION: Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Specialty Behavioral Health Care Utilization and Spending Among Carve-In Enrollees.

OBJECTIVE: The federal Mental Health Parity and Addiction Equity Act (MHPAEA) sought to eliminate historical disparities between insurance coverage for behavioral health (BH) treatment and coverage for medical treatment. Our objective was to evaluate MHPAEA's impact on BH expenditures and utilization among "carve-in" enrollees. METHODS: We received specialty BH insurance claims and eligibility data from Optum, sampling 5,987,776 adults enrolled in self-insured plans from large employers. An interrupted time series study design with segmented regression analysis estimated monthly time trends of per-member spending and use before (2008-2009), during (2010), and after (2011-2013) MHPAEA compliance (N=179,506,951 member-month observations). Outcomes included: total, plan, patient out-of-pocket spending; outpatient utilization (assessment/diagnostic evaluation visits, medication management, individual and family psychotherapy); intermediate care utilization (structured outpatient, day treatment, residential); and inpatient utilization. RESULTS: MHPAEA was associated with increases in monthly per-member total spending, plan spending, assessment/diagnostic evaluation visits [respective immediate increases of: $1.05 (P=0.02); $0.88 (P=0.04); 0.00045 visits (P=0.00)], and individual psychotherapy visits [immediate increase of 0.00578 visits (P=0.00) and additional increases of 0.00017 visits/mo (P=0.03)]. CONCLUSIONS: MHPAEA was associated with modest increases in total and plan spending and outpatient utilization; for example, in July 2012 predicted per-enrollee plan spending was $4.92 without MHPAEA and $6.14 with MHPAEA. Efforts should focus on understanding how other barriers to BH care unaddressed by MHPAEA may affect access/utilization. Future research should evaluate effects produced by the Affordable Care Act's inclusion of BH care as an essential health benefit and expansion of MHPAEA protections to the individual and small group markets.

A comparison of nursing tasks undertaken by regulated nurses and nursing support workers: a work sampling study.

AIMS: The aim of this study was to determine which tasks unregulated nursing support staff spend their work time undertaking and to determine differences between the work undertaken by licensed/regulated nurses on units which have nursing support workers and those on units which do not. BACKGROUND: Acute hospital nursing teams often include nursing support staff; little is known about what kinds of tasks these unregulated support workers do and how it affects the work tasks of their licensed/regulated team members. DESIGN: Cross-sectional analysis of nurse work sampling data. METHODS: Data collection took place between March-October 2013. The proportion of time spent on 25 work activities by nursing support staff and licensed/regulated nursing staff was compared. Logistic regression models estimated whether nursing support staff or licensed/regulated nurses were more likely to conduct direct and indirect patient care tasks and whether licensed/regulated nurses on units with nursing support staff were more likely to conduct direct or indirect tasks compared with those on units without nursing support workers. RESULTS: Nursing support staff spent the majority of their time engaged in direct care tasks, e.g. admission and assessment, hygiene and mobility. Although licensed/regulated nurses were less likely to undertake direct care tasks compared with support workers, those who worked on units with support workers undertook more direct care compared with those who worked on units without support workers. CONCLUSIONS: Nursing support workers were given tasks that required substantial amounts of patient interaction. These staff may be associated with an increase in direct care tasks for licensed/regulated nurses, who may duplicate the direct care done by nursing support workers.

Regulated and unregulated nurses in the acute hospital setting: Tasks performed, delayed or not completed.

AIMS: Investigate the number and type of tasks performed, delayed or not completed by regulated and unregulated (assistant) nurses. BACKGROUND: Assistants in Nursing change the work environment of the nurses with whom they work. As the number of Assistants in Nursing working on acute units grows, it is important to understand how their presence influences nursing care. DESIGN: Descriptive analysis of survey data from 62 acute nursing units across three Australian states between 2008-2010. METHODS: All staff providing nursing care to patients were asked to complete a survey that included demographics, the number of tasks delayed/incomplete and the completion of six specific tasks. Nonparametric tests compared Assistants in Nursing (n = 25) to regulated nurses (n = 1630), and regulated nurses on units with no Assistants in Nursing (n = 1356) to those on units with up to 5% assistants (n = 76) and over 5% assistants (n = 198). RESULTS: More regulated nurses on units with zero, or up to 5% Assistants in Nursing, completed tasks usually associated with assistants' scope of practice, relative to those on units with over 5% Assistants in Nursing. Statistically significant differences were found between the units in delays responding to the patient bell and in the planning of nursing care. CONCLUSION: This study suggests that Assistants in Nursing have an impact on the nature and timeliness of care provided in acute hospital units, that is relative to the proportion of staffing they comprise, to the effectiveness of integration and to the clarity of their scope of practice and associated delegation. RELEVANCE TO CLINICAL PRACTICE: With increasing employment of Assistants in Nursing in acute hospital settings comes the requirement to optimise their use. This needs to include a well-articulated scope of practice, clear delegation of tasks and effective integration with the rest of the care team.