Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data

Background: The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK’s pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. ‘Population achievement’ describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. Methods: We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. Results: Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010–2011; 7.02% in 2011–2012 and 6.92% in 2012–2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010–2011; 0.88% in 2011–2012 and 0.96% in 2012–2013). Median population achievement was 83.5% (83.51% in 2010–2011; 83.41% in 2011–2012 and 83.63% in 2012–2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland’s most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83–2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices. Conclusions: Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the ‘hard to reach’ if inequalities in healthcare delivery are to be tackled

Male lyrebirds create a complex acoustic illusion of a mobbing flock during courtship and copulation

Darwin argued that females’ “taste for the beautiful” drives the evolution of male extravagance,1 but sexual selection theory also predicts that extravagant ornaments can arise from sexual conflict and deception.2,3 The sensory trap hypothesis posits that elaborate sexual signals can evolve via antagonistic coevolution whereby one sex uses deceptive mimicry to manipulate the opposite sex into mating.3 Here, the success of deceptive mimicry depends on whether it matches the receiver’s percept of the model,4 and so has little in common with concepts of aesthetic judgement and ‘beauty.’1,5,6,7,8,9 We report that during their song and dance displays,10 male superb lyrebirds (Menura novaehollandiae) create an elaborate acoustic illusion of a mixed-species mobbing flock. Acoustic analysis showed that males mimicked the mobbing alarm calls of multiple species calling together, enhancing the illusion by also vocally imitating the wingbeats of small birds. A playback experiment confirmed that this illusion was sufficient to fool avian receivers. Furthermore, males produced this mimicry only (1) when females attempted to exit male display arenas, and (2) during the lyrebirds’ unusually long copulation, suggesting that the mimicry aims to prevent females from prematurely terminating these crucial sexual interactions. Such deceptive behavior by males should select for perceptual acuity in females, prompting an inter-sexual co-evolutionary arms race between male mimetic accuracy and discrimination by females. In this way the elaboration of the complex avian vocalizations we call ‘song’ could be driven by sexual conflict, rather than a female’s preference for male extravagance

Male lyrebirds create a complex acoustic illusion of a mobbing flock during courtship and copulation

Darwin argued that females’ “taste for the beautiful” drives the evolution of male extravagance, but sexual selection theory also predicts that extravagant ornaments can arise from sexual conflict and deception. , The sensory trap hypothesis posits that elaborate sexual signals can evolve via antagonistic coevolution whereby one sex uses deceptive mimicry to manipulate the opposite sex into mating. Here, the success of deceptive mimicry depends on whether it matches the receiver\u27s percept of the model, and so has little in common with concepts of aesthetic judgement and ‘beauty.’ , We report that during their song and dance displays, male superb lyrebirds (Menura novaehollandiae) create an elaborate acoustic illusion of a mixed-species mobbing flock. Acoustic analysis showed that males mimicked the mobbing alarm calls of multiple species calling together, enhancing the illusion by also vocally imitating the wingbeats of small birds. A playback experiment confirmed that this illusion was sufficient to fool avian receivers. Furthermore, males produced this mimicry only (1) when females attempted to exit male display arenas, and (2) during the lyrebirds’ unusually long copulation, suggesting that the mimicry aims to prevent females from prematurely terminating these crucial sexual interactions. Such deceptive behavior by males should select for perceptual acuity in females, prompting an inter-sexual co-evolutionary arms race between male mimetic accuracy and discrimination by females. In this way the elaboration of the complex avian vocalizations we call ‘song’ could be driven by sexual conflict, rather than a female\u27s preference for male extravagance. 1 2 3 3 4 1 5–9 1

Destruction of a conspecific nest by a female Superb Lyrebird : evidence for reproductive suppression in a bird with female-only parental care

Reproductive suppression, whereby individuals decrease the reproductive output of conspecific rivals, is well-studied in mammals, but while it is suspected to be widespread in birds, evidence of this phenomenon remains rare in this class. Here we provide compelling evidence of reproductive suppression in the Superb Lyrebird (Menura novaehollandie), with the first audio-visual documentation of the destruction of one female's nest by another. We propose that nest destruction may be a strategy that females use in protracted territorial negotiations spanning multiple breeding seasons, and discuss how reproductive suppression could explain puzzling nesting behaviours in this species, such as the construction of multiple unfinished nests in each breeding season. More broadly, these results reveal high intra-sexual competition among female lyrebirds, and thus may provide an explanation for their elaborate vocal displays

Dance choreography is coordinated with song repertoire in a complex avian display

All human cultures have music and dance [1, 2], and the two activities are so closely integrated that many languages use just one word to describe both [1, 3]. Recent research points to a deep cognitive connection between music and dance-like movements in humans [2, 4–6], fueling speculation that music and dance have coevolved [2, 7, 8] and prompting the need for studies of audiovisual displays in other animals [9, 10]. However, little is known about how nonhuman animals integrate acoustic and movement display components [11, 12]. One striking property of human displays is that performers coordinate dance with music by matching types of dance movements with types of music, as when dancers waltz to waltz music. Here, we show that a bird also temporally coordinates a repertoire of song types with a repertoire of dance-like movements. During displays, male superb lyrebirds (Menura novaehollandiae) sing four different song types, matching each with a unique set of movements and delivering song and dance types in a predictable sequence. Crucially, display movements are both unnecessary for the production of sound and voluntary, because males sometimes sing without dancing. Thus, the coordination of independently produced repertoires of acoustic and movement signals is not a uniquely human trait

Preferred nesting habitat of the slow-breeding Superb Lyrebird is rare and was disproportionately impacted by Australia’s “Black Summer” megafires (2019–2020) within a World Heritage Area

Understanding nest site selection is critical to developing effective conservation management actions. The Superb Lyrebird (Menura novaehollandiae) is one of many endemic species extensively impacted by Australia’s unprecedented 2019–2020 megafires. Over a period of 5 months, an estimated 43% of the entire range of this slow-breeding species was burnt, with the biggest impact on the central subspecies M. n. novaehollandiae (55%). Four months prior to these megafires, we conducted a field study of nest site habitat selection in the Superb Lyrebird within the Greater Blue Mountains World Heritage Area (15,400 km2): a key stronghold of the central subspecies of the Superb Lyrebird. We found that at the local scale, lyrebird nest sites were more likely to be found in habitats characterized by dense canopy trees and rich in rainforest elements such as vines and treeferns. At the landscape scale, lyrebird nests were most likely to be constructed in rainforest; this fire-sensitive habitat type made up only 1% of the Greater Blue Mountains World Heritage Area. The probability of nest occurrence also increased with slope. We also found that \u3e74% of all nesting habitat within the Greater Blue Mountains World Heritage Area burned in the 2019–2020 megafires, including 80% of areas of high suitability for nesting. These results suggest that the impact of these megafires on Superb Lyrebirds may be greater than currently thought. Given the importance of rainforest as nesting habitat for the Superb Lyrebird, managers should prioritize its restoration and protect it from future fire events. More broadly, our results illustrate how large-scale catastrophic events—such as megafires—can disproportionately affect habitats critical to specific points within an organism’s life cycle

Synthesis of the positron-emitting radiotracer [18F]-2-fluoro-2-deoxy-d-glucose from resin-bound perfluoroalkylsulfonates

A new approach to the synthesis of 2-fluoro-2-deoxy-D-glucose (FDG, [19/18F]- 3) is described, which employs supported perfluoroalkylsulfonate precursors 33–36, where the support consists of insoluble polystyrene resin beads. Treatment of these resins with [19F]fluoride ion afforded protected FDG [19F]- 18 as the major product, and the identities of the main byproducts were determined. Acidic removal of the acetal protecting groups from [19F]- 18 was shown to produce [19F]FDG. The method has been applied to the efficient radiosynthesis of the imaging agent [18F]FDG, and was shown to produce the radiochemical tracer in good radiochemical yield (average 73%, decay corrected)