Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams. The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy

An estimate of the electron density in filaments of galaxies at z~0.1

Most of the baryons in the Universe are thought to be contained within filaments of galaxies, but as yet, no single study has published the observed properties of a large sample of known filaments to determine typical physical characteristics such as temperature and electron density. This paper presents a comprehensive large-scale search conducted for X-ray emission from a population of 41 bona fide filaments of galaxies to determine their X-ray flux and electron density. The sample is generated from Pimbblet et al.'s (2004) filament catalogue, which is in turn sourced from the 2 degree Field Galaxy Redshift Survey (2dFGRS). Since the filaments are expected to be very faint and of very low density, we used stacked ROSAT All-Sky Survey data. We detect a net surface brightness from our sample of filaments of (1.6 +/- 0.1) x 10^{-14} erg cm^{-2} s^{-1} arcmin^{-2} in the 0.9-1.3 keV energy band for 1 keV plasma, which implies an electron density of n_{e} = (4.7 +/- 0.2) x 10^{-4} h_{100}^{1/2} cm^{-3}. Finally, we examine if a filament's membership to a supercluster leads to an enhanced electron density as reported by Kull & Bohringer (1999). We suggest it remains unclear if supercluster membership causes such an enhancement.Comment: Accepted for publication in MNRAS. v2: typos correcte

Cavity ringdown studies of the E–H transition in an inductively coupled oxygen plasma: comparison of spectroscopic measurements and modelling

The absolute number density of ground state oxygen atoms, O(3P), present in a 100 mTorr oxygen plasma has been determined as a function of operating power using cavity ringdown spectroscopy (CRDS). The dissociation fraction increases by an order of magnitude from ∼0.8% at 50 W to 8% at 250 W and reflects a similar increase in the electron density over this power range. Emission spectra show that the E–H switchover is accompanied by increased rotational heating of O2 and this behaviour is also observed in the translational temperatures determined by fitting the Doppler limited O(3P) CRDS data. The measurements are contextualised via a volume averaged kinetic model that uses the measured absolute densities of O(3P) and O2(a1Δg, v = 0) as a function of power as its benchmarks. Despite the inherent spatial inhomogeneity of the plasma, the volume averaged model, which uses a minimal set of reactions, is able to both reproduce previous measurements on the absolute density of O− and to infer physically reasonable values for both the electron temperature and number density as the E–H switch over is traversed. Time-resolved emission measurements return a value of 0.2 for the wall loss coefficient for O2(b1Σg+); as a consequence, the number density of O2(b1Σg+) is (at least) one order of magnitude less than O2(a1Δg)

Comprehensive ECG reference intervals in C57BL/6N substrains provide a generalizable guide for cardiac electrophysiology studies in mice.

Reference ranges provide a powerful tool for diagnostic decision-making in clinical medicine and are enormously valuable for understanding normality in pre-clinical scientific research that uses in vivo models. As yet, there are no published reference ranges for electrocardiography (ECG) in the laboratory mouse. The first mouse-specific reference ranges for the assessment of electrical conduction are reported herein generated from an ECG dataset of unprecedented scale. International Mouse Phenotyping Consortium data from over 26,000 conscious or anesthetized C57BL/6N wildtype control mice were stratified by sex and age to develop robust ECG reference ranges. Interesting findings include that heart rate and key elements from the ECG waveform (RR-, PR-, ST-, QT-interval, QT corrected, and QRS complex) demonstrate minimal sexual dimorphism. As expected, anesthesia induces a decrease in heart rate and was shown for both inhalation (isoflurane) and injectable (tribromoethanol) anesthesia. In the absence of pharmacological, environmental, or genetic challenges, we did not observe major age-related ECG changes in C57BL/6N-inbred mice as the differences in the reference ranges of 12-week-old compared to 62-week-old mice were negligible. The generalizability of the C57BL/6N substrain reference ranges was demonstrated by comparison with ECG data from a wide range of non-IMPC studies. The close overlap in data from a wide range of mouse strains suggests that the C57BL/6N-based reference ranges can be used as a robust and comprehensive indicator of normality. We report a unique ECG reference resource of fundamental importance for any experimental study of cardiac function in mice

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine

[This corrects the article DOI: 10.1186/s13054-016-1208-6.]

Efficacy and safety of baricitinib or ravulizumab in adult patients with severe COVID-19 (TACTIC-R): a randomised, parallel-arm, open-label, phase 4 trial

Background From early in the COVID-19 pandemic, evidence suggested a role for cytokine dysregulation and complement activation in severe disease. In the TACTIC-R trial, we evaluated the efficacy and safety of baricitinib, an inhibitor of Janus kinase 1 (JAK1) and JAK2, and ravulizumab, a monoclonal inhibitor of complement C5 activation, as an adjunct to standard of care for the treatment of adult patients hospitalised with COVID-19. Methods TACTIC-R was a phase 4, randomised, parallel-arm, open-label platform trial that was undertaken in the UK with urgent public health designation to assess the potential of repurposing immunosuppressants for the treatment of severe COVID-19, stratified by a risk score. Adult participants (aged ≥18 years) were enrolled from 22 hospitals across the UK. Patients with a risk score indicating a 40% risk of admission to an intensive care unit or death were randomly assigned 1:1:1 to standard of care alone, standard of care with baricitinib, or standard of care with ravulizumab. The composite primary outcome was the time from randomisation to incidence (up to and including day 14) of the first event of death, invasive mechanical ventilation, extracorporeal membrane oxygenation, cardiovascular organ support, or renal failure. The primary interim analysis was triggered when 125 patient datasets were available up to day 14 in each study group and we included in the analysis all participants who were randomly assigned. The trial was registered on ClinicalTrials.gov (NCT04390464). Findings Between May 8, 2020, and May 7, 2021, 417 participants were recruited and randomly assigned to standard of care alone (145 patients), baricitinib (137 patients), or ravulizumab (135 patients). Only 54 (39%) of 137 patients in the baricitinib group received the maximum 14-day course, whereas 132 (98%) of 135 patients in the ravulizumab group received the intended dose. The trial was stopped after the primary interim analysis on grounds of futility. The estimated hazard ratio (HR) for reaching the composite primary endpoint was 1·11 (95% CI 0·62–1·99) for patients on baricitinib compared with standard of care alone, and 1·53 (0·88–2·67) for ravulizumab compared with standard of care alone. 45 serious adverse events (21 deaths) were reported in the standard-of-care group, 57 (24 deaths) in the baricitinib group, and 60 (18 deaths) in the ravulizumab group. Interpretation Neither baricitinib nor ravulizumab, as administered in this study, was effective in reducing disease severity in patients selected for severe COVID-19. Safety was similar between treatments and standard of care. The short period of dosing with baricitinib might explain the discrepancy between our findings and those of other trials. The therapeutic potential of targeting complement C5 activation product C5a, rather than the cleavage of C5, warrants further evaluation

Nonlinear Physician Performance Contracts

Policymakers have increasingly focused on the design of provider contracts to reduce health care costs and increase care quality. Many of these contracts provide bonus payments to providers contingent on meeting externally set performance threshold levels. Using data from a large insurer in Hawaii, this paper estimates physician responsiveness to two features of these contracts - 1) threshold level and 2) bonus amount - for ten preventative process measures. I estimate provider performance response using a large discrete change in a single measure\u27s threshold level and bonus amount during the sample period. I also estimate a pooled provider performance response across all measures using two instrumental variables. I find that a one percentage point increase in threshold location leads to a 0.3 to 0.5 percentage point increase in performance the subsequent quarter. I do not detect an average response to bonus size. Next I explore mechanisms for these responses. I find heterogeneous responses based on prior performance: low performing physicians are more responsive to threshold level, and high performing physicians are responsive to bonus amount. I do not find evidence for physicians increasing effort near the end of a time period alleviating concerns over decreased access for other types of patients. Finally, I find some evidence that the additional patients screened are higher risk and higher cost suggesting the marginal benefit of screening increases. My results demonstrate that the marginal bonus amount has little effect on provider effort and incentivizes already high-performing physicians. Small increases in threshold levels improves performance without increasing cost. These results have implications for innovations in physician payment models and contract designs

Nonlinear Physician Performance Contracts

Policymakers have increasingly focused on the design of provider contracts to reduce health care costs and increase care quality. Many of these contracts provide bonus payments to providers contingent on meeting externally set performance threshold levels. Using data from a large insurer in Hawaii, this paper estimates physician responsiveness to two features of these contracts - 1) threshold level and 2) bonus amount - for ten preventative process measures. I estimate provider performance response using a large discrete change in a single measure\u27s threshold level and bonus amount during the sample period. I also estimate a pooled provider performance response across all measures using two instrumental variables. I find that a one percentage point increase in threshold location leads to a 0.3 to 0.5 percentage point increase in performance the subsequent quarter. I do not detect an average response to bonus size. Next I explore mechanisms for these responses. I find heterogeneous responses based on prior performance: low performing physicians are more responsive to threshold level, and high performing physicians are responsive to bonus amount. I do not find evidence for physicians increasing effort near the end of a time period alleviating concerns over decreased access for other types of patients. Finally, I find some evidence that the additional patients screened are higher risk and higher cost suggesting the marginal benefit of screening increases. My results demonstrate that the marginal bonus amount has little effect on provider effort and incentivizes already high-performing physicians. Small increases in threshold levels improves performance without increasing cost. These results have implications for innovations in physician payment models and contract designs

Nonlinear Physician Performance Contracts

Policymakers have increasingly focused on the design of provider contracts to reduce health care costs and increase care quality. Many of these contracts provide bonus payments to providers contingent on meeting externally set performance threshold levels. Using data from a large insurer in Hawaii, this paper estimates physician responsiveness to two features of these contracts - 1) threshold level and 2) bonus amount - for ten preventative process measures. I estimate provider performance response using a large discrete change in a single measure\u27s threshold level and bonus amount during the sample period. I also estimate a pooled provider performance response across all measures using two instrumental variables. I find that a one percentage point increase in threshold location leads to a 0.3 to 0.5 percentage point increase in performance the subsequent quarter. I do not detect an average response to bonus size. Next I explore mechanisms for these responses. I find heterogeneous responses based on prior performance: low performing physicians are more responsive to threshold level, and high performing physicians are responsive to bonus amount. I do not find evidence for physicians increasing effort near the end of a time period alleviating concerns over decreased access for other types of patients. Finally, I find some evidence that the additional patients screened are higher risk and higher cost suggesting the marginal benefit of screening increases. My results demonstrate that the marginal bonus amount has little effect on provider effort and incentivizes already high-performing physicians. Small increases in threshold levels improves performance without increasing cost. These results have implications for innovations in physician payment models and contract designs