Pursuing High Performance in Rural Health Care

In 2001, the Institute of Medicine (IOM) called for transformation of the United States health care system to make it safe, effective, patient-centered, timely, efficient, and equitable.1 The journey toward these six aims in public policy and the private sector is underway, but fundamental challenges detailed by the IOM remain. Patients are injured at alarming rates, wide variation in care exists across geographies, patients complain of insensitive and/or inaccessible health care providers, health care costs are nearly twice that in other developed countries, and nearly 50 million Americans lack health insurance. As a result, our health care is often fragmented, uncoordinated, and excessively costly. In fact, the United States health care system has been called a “non-system.” The rural health care landscape is additionally challenged by independent and autonomous providers often struggling to survive financially, burdensome geographic separations in health care services, and incompatible information technologies. As a result, resources are wasted, patients are harmed, and rural communities are neglected. Despite persistent rural challenges, public policies during the past 30 years have helped build and stabilize rural health care services. New payments have increased revenue for physicians practicing in shortage areas, rural hospitals certified as Critical Access Hospitals (very small hospitals in isolated places), Sole Community Hospitals (larger hospitals also in isolated areas), and Rural Health Clinics (primary care clinics staffed by nurse practitioners and/or physician assistants). New programs continue to provide technical assistance and grants to rural hospitals (Medicare Rural Hospital Flexibility Program), fund installation of telemedicine equipment, and promote rural health professions education. These successes have required political capital and developmental resources to support a system that delivers discrete and uncoordinated health care services, provided by specific professionals and institutions, each paid on a per-service basis. Yet, progressive work by the Institute of Medicine (especially the Rural Health Committee document Quality Through Collaboration: The Future of Rural Health Care), the Commonwealth Commission on a High Performance Healthcare System, and other organizations suggest more effective strategies to improve and sustain the health of rural people..

Advancing the Transition to a High Performance Rural Health System

There are growing concerns about the current and future state of rural health. Despite decades of policy efforts to stabilize rural health systems through a range of policies and loan and grant programs, accelerating rural hospital closures combined with rapid changes in private and public payment strategies have created widespread concern that these solutions are inadequate for addressing current rural health challenges. The rural health system of today is the product of legacy policies and programs that often do not “fit” current local needs. Misaligned incentives undermine high-value and efficient care delivery. While there are limitations related to scalability in rural health system development, rural communities do have enormous potential to achieve the objectives of a high performance rural health system. This brief (and a companion paper at http://www.rupri.org/areas-of-work/health-policy/) discusses strategies and options for creating a pathway to a transformed, high performing rural health system

Pursuing High Performance in Rural Health Care

Rural Futures Lab Foundation Papers are intended to present current thinking on the economic drivers and opportunities that will shape the future of rural America. They provide the foundation upon which it will be possible to answer the question that drives the Lab’s work—What has to happen today in order to achieve positive rural outcomes tomorrow

Incidence, patterns and severity of reported unintentional injuries in Pakistan for persons five years and older: results of the National Health Survey of Pakistan 1990–94

<p>Abstract</p> <p>Background</p> <p>National level estimates of injuries are not readily available for developing countries. This study estimated the annual incidence, patterns and severity of unintentional injuries among persons over five years of age in Pakistan.</p> <p>Methods</p> <p>National Health Survey of Pakistan (NHSP 1990–94) is a nationally representative survey of the household. Through a two-stage stratified design, 18, 315 persons over 5 years of age were interviewed to estimate the overall annual incidence, patterns and severity of unintentional injuries for males and females in urban and rural areas over the preceding one year. Weighted estimates were computed adjusting for complex survey design using <it>surveyfreq </it>and <it>surveylogistic </it>option of SAS 9.1 software.</p> <p>Results</p> <p>The overall annual incidence of all unintentional injuries was 45.9 (CI: 39.3–52.5) per 1000 per year; 59.2 (CI: 49.2–69.2) and 33.2 (CI: 27.0–39.4) per 1000 per year among males and females over five years of age, respectively. An estimated 6.16 million unintentional injuries occur in Pakistan annually among persons over five years of age. Urban and rural injuries were 55.9 (95% CI: 48.1–63.7) and 41.2 (95% CI: 32.2–50.0) per 1000 per year, respectively. The annual incidence of injuries due to falls were 22.2 (95% CI: 18.0–26.4), poisoning 3.3 (95%CI: 0.5–6.1) and burn was 1.5 (95%CI: 0.9–2.1) per 1000 per year. The majority of injuries occurred at home 19.2 (95%CI: 16.0–22.4) or on the roads 17.0 (95%CI: 13.8–20.2). Road traffic/street, school and urban injuries were more likely to result in handicap.</p> <p>Conclusion</p> <p>There is high burden of unintentional injuries among persons over five years of age in Pakistan. These results are useful to plan further studies and prioritizing prevention programs on injuries nationally and other developing countries with similar situation.</p

Label-free chemically specific imaging in planta with stimulated Raman scattering microscopy.

The growing world population puts ever-increasing demands on the agricultural and agrochemical industries to increase agricultural yields. This can only be achieved by investing in fundamental plant and agrochemical research and in the development of improved analytical tools to support research in these areas. There is currently a lack of analytical tools that provide noninvasive structural and chemical analysis of plant tissues at the cellular scale. Imaging techniques such as coherent anti-Stokes Raman scattering (CARS) and stimulated Raman scattering (SRS) microscopy provide label-free chemically specific image contrast based on vibrational spectroscopy. Over the past decade, these techniques have been shown to offer clear advantages for a vast range of biomedical research applications. The intrinsic vibrational contrast provides label-free quantitative functional analysis, it does not suffer from photobleaching, and it allows near real-time imaging in 3D with submicrometer spatial resolution. However, due to the susceptibility of current detection schemes to optical absorption and fluorescence from pigments (such as chlorophyll), the plant science and agrochemical research communities have not been able to benefit from these techniques and their application in plant research has remained virtually unexplored. In this paper, we explore the effect of chlorophyll fluorescence and absorption in CARS and SRS microscopy. We show that with the latter it is possible to use phase-sensitive detection to separate the vibrational signal from the (electronic) absorption processes. Finally, we demonstrate the potential of SRS for a range of in planta applications by presenting in situ chemical analysis of plant cell wall components, epicuticular waxes, and the deposition of agrochemical formulations onto the leaf surface

A Common CNR1 (Cannabinoid Receptor 1) Haplotype Attenuates the Decrease in HDL Cholesterol That Typically Accompanies Weight Gain

We have previously shown that genetic variability in CNR1 is associated with low HDL dyslipidemia in a multigenerational obesity study cohort of Northern European descent (209 families, median  = 10 individuals per pedigree). In order to assess the impact of CNR1 variability on the development of dyslipidemia in the community, we genotyped this locus in all subjects with class III obesity (body mass index >40 kg/m2) participating in a population-based biobank of similar ancestry. Twenty-two haplotype tagging SNPs, capturing the entire CNR1 gene locus plus 15 kb upstream and 5 kb downstream, were genotyped and tested for association with clinical lipid data. This biobank contains data from 645 morbidly obese study subjects. In these subjects, a common CNR1 haplotype (H3, frequency 21.1%) is associated with fasting TG and HDL cholesterol levels (p = 0.031 for logTG; p = 0.038 for HDL-C; p = 0.00376 for log[TG/HDL-C]). The strength of this relationship increases when the data are adjusted for age, gender, body mass index, diet and physical activity. Mean TG levels were 160±70, 155±70, and 120±60 mg/dL for subjects with 0, 1, and 2 copies of the H3 haplotype. Mean HDL-C levels were 45±10, 47±10, and 48±9 mg/dL, respectively. The H3 CNR1 haplotype appears to exert a protective effect against development of obesity-related dyslipidemia

NUCLEAR MERCHANT SHIP REACTOR PROJECT. EXTENDED ZERO POWER TESTS NS SAVANNAH CORE I. Final Report

Experiments were performed on the NS Savannah Service Core I to supply irformation on future shipboard operation of the Nuclear Merchant Ship Reactor. Testing of instrumentation equipment was satisfactory. Correction factors for shipboard use were determined. Fast neutron flux, neutron fiux distribution, and stuck control rod studies were carried out successfully, as was a three- dimesional calculation to match two critical rod patterns. (auth