The role of data in health care disparities in medicaid managed care

BACKGROUND: The Affordable Care Act includes provisions to standardize the collection of data on health care quality that can be used to measure disparities. We conducted a qualitative study among leaders of Medicaid managed care plans, that currently have access to standardized quality data stratified by race and ethnicity, to learn how they use it to address disparities. METHODS: We conducted semi-structured interviews with 21 health plan leaders across 9 Medicaid managed care plans in California. We used purposive sampling to maximize heterogeneity in geography and plan type (e.g., non-profit, commercial). We performed a thematic analysis based on iterative coding by two investigators. RESULTS: We found 4 major themes. Improving overall quality was tightly linked to a focus on standardized metrics that are integral to meeting regulatory or financial incentives. However, reducing disparities was not driven by standardized data, but by a mix of factors. Data were frequently only examined by race and ethnicity when overall performance was low. Disparities were attributed to either individual choices or cultural and linguistic factors, with plans focusing interventions on recently immigrated groups. CONCLUSIONS: While plans' efforts to address overall quality were often informed by standardized data, actions to reduce disparities were not, at least partly because there were few regulatory or financial incentives driving meaningful use of data on disparities. Standardized data, as envisaged by the Affordable Care Act, could become more useful for addressing disparities if they are combined with policies and regulations that promote health care equity

Histoire de l’art britannique 1750-1850 : un état des lieux

Grâce à une active collaboration entre universités, musées (Tate Britain, Yale Center for British Art) et centres de recherches (Warburg Institute, Paul Mellon Centre…), les recherches sur l’art britannique entre 1750 et 1850 se sont remarquablement structurées et enrichies depuis une trentaine d’années (élaboration de catalogues raisonnés, expositions thématiques, symposiums réguliers, bourses de recherche). Ces orientations nouvelles ont permis l’inscription de la production artistique britannique, en particulier à l’époque romantique, dans le contexte international (notamment italien et allemand). Non seulement des artistes jusque là laissés dans l’ombre (Stubbs, Wright of Derby, Rysbrack…), ont été étudiés, mais surtout les approches se sont élargies à l’histoire sociale de l’art (et non seulement institutionnelle ou économique), nourrissant de féconds échanges avec l’histoire littéraire, et intègrent maintenant les théories féministes et postcoloniales, abordant les problématiques du rôle des artistes dans la formation de l’identité nationale ou de la représentation des non-Européens.Thanks to the active collaboration between universities, museums (Tate Britain, Yale Centre for British Art) and research centres (Warburg Institute, Paul Mellon Center), studies on British art from the period between 1750 and 1850 have been remarkably enriched and restructured within the past thirty years (catalogues raisonnés, thematic exhibitions, regular symposiums, research grants). These new directions have made it possible to resituate British artistic production, in particular from the Romantic period, within an international context (especially Italian and German). Not only have formerly forgotten artists (Stubbs, Wright of Derby, Rysbrack…) been brought to light, but, more importantly, approaches have been broadened to include the social history of art (and not only its institutional or economic history) – nourished by fertile exchanges with literary history – and now integrate feminist and postcolonial theory, thus raising questions on the role of artists in the creation of national identity and the representation of non-Europeans.Dank der aktiven Zusammenarbeit von Universitäten, Museen (Tate Britain, Yale Center for British Art) und Forschungszentren (Warburg Institute, Paul Mellon Centre…) hat sich die Forschung im Bereich der britischen Kunst zwischen 1750 und 1850 seit den letzten dreißig Jahren erstaunlich strukturiert und bereichert (Erstellung von Werkverzeichnissen, Organisation von thematischen Ausstellungen, regelmäßigen Symposien und Forschungsstipendien). Diese neuen Orientierungen haben es ermöglicht, die britische Kunstproduktion, besonders die der Romantik, in einen internationalen Zusammenhang (zum Beispiel im Vergleich mit der deutschen und italienischen Kunst) zu setzen. Dabei wurden nicht nur die bis dahin wenig beachteten Künstler (Stubbs, Wright of Derby, Rysbrack…) aufgegriffen, sondern vor allem die Forschungsansätze erweitert. Neben der sozialen Geschichte der Kunst, die über institutionelle und wirtschaftliche Fragen hinaus auch einen ergiebigen Austausch mit der Literaturgeschichte verfolgt, nehmen diese neuen Ansätze mittlerweile auch die feministischen und postkolonialen Theorien auf, die verschiedene Fragestellungen zur Rolle des Künstlers in der Bildung einer nationalen Identität oder zur Darstellung der Nichteuropäer untersuchen.Grazie alla collaborazione attiva fra università, musei (Tate Britain, Yale Center for Britisch Art) e centri di ricerca (Warburg Institute, Paul Mellon Centre…), le ricerche sull’arte britannica fra il 1750 e il 1850 si sono, da una trentina d’anni, notevolmente strutturate e arricchite (elaborazione di cataloghi ragionati, convegni frequenti, borse di ricerca). Questi nuovi orientamenti hanno permesso che la produzione artistica britannica, in particolare quella dell’epoca romantica, prendesse posto nel contesto internazionale (soprattutto italiano e tedesco). Non solamente artisti rimasti nell’ombra (Stubbs, Wright of Derby, Rysbrack…) sono stati studiati, ma soprattutto i diversi approcci si sono estesi alla storia sociale dell’arte (e non solo istituzionale o economica), nutrendo scambi fecondi con la storia della letteratura ; le ricerche integranno, oggi, anche le teorie femministe e postcolonialiste, prendendo in considerazione le problematiche relative al ruolo degli artisti nella formazione dell’identità nazionale o alla rappresentatività dei non Europei.Gracias a una colaboración activa entre universidades, museos (Tate Britain, Yale Center for British Art) y centros de investigaciones (Warburg Institute, Paul Mellon Centre...), la investigación sobre el arte británico entre 1750 y 1850 se ha ido estructurando y enriqueciendo notablemente desde hace unos treinta años (elaboración de catálogos razonados, exposiciones temáticas, simposios regulares, becas de investigación). Estas nuevas orientaciones han permitido la inscripción de la producción artística británica, en particular la del período romántico, dentro del contexto internacional (en particular italiano y alemán). No sólo se estudió a unos artistas hasta en la sombra (Stubbs, Wright of Derby, Rysbrack...) hasta aquel entonces, sino que sobre todo los enfoques se ampliaron a la historia social del arte (y no solamente institucional o económica), generando intercambios fertiles con la historia literaria, e integran ahora las teorías feministas y postcoloniales, abordando la problemática del papel de los artistas en la formación de la identidad nacional o la representación de los no-europeos

From Vampire to Apollo: William Blake's Ghosts of the Flea (c. 1819-20)

Varley’s Zodiacal Physiognomy and Blake’s Visionary Heads are the two mainstays of a project which involved séance-like meetings at Varley’s house. While the lights were still on, Varley’s guests would have listened to the stories about the flea. With The Ghost of a Flea in front of them, the recitals of the flea’s pompous speeches, combined with the fact that it was just a ghost who leered after human blood, Varley’s guests may have laughed very heartily, if not in front of him then behind his back. Each evening followed the same protocol. When the lights were off, Varley would call out a name and Blake would look around, suddenly exclaiming ‘There he is!’ and start drawing. The flea is the most striking of the Visionary Heads, though it is not the only head which exists in different versions. If appearance is elemental to any kind of judgement of one human being of another, then Blake deliberately confused Varley. By working up the sketch, he played on Varley’s expectations; he presented him with an extraordinary and very puzzling painting, The Ghost of a Flea. But why, if Blake could have chosen any monster, did he settle on the ghost of a flea

Patient-Centered Outcomes Measurement: Does It Require Information From Patients?

Purpose: Since collecting outcome measure data from patients can be expensive, time-consuming, and subject to memory and nonresponse bias, we sought to learn whether outcomes important to patients can be obtained from data in the electronic health record (EHR) or health insurance claims. Methods: We previously identified 21 outcomes rated important by patients who had advanced imaging tests for back or abdominal pain. Telephone surveys about experiencing those outcomes 1 year after their test from 321 people consenting to use of their medical record and claims data were compared with audits of the participants’ EHR progress notes over the time period between the imaging test and survey completion. We also compared survey data with algorithmically extracted data from claims files for outcomes for which data might be available from that source. Results: Of the 16 outcomes for which patients’ survey responses were considered to be the best information source, only 2 outcomes for back pain and 3 for abdominal pain had kappa scores above a very modest level of ≥ 0.2 for chart audit of EHR data and none for algorithmically obtained EHR/claims data. Of the other 5 outcomes for which claims data were considered to be the best information source, only 2 outcomes from patient surveys and 3 outcomes from chart audits had kappa scores ≥ 0.2. Conclusions: For the types of outcomes studied here, medical record or claims data do not provide an adequate source of information except for a few outcomes where patient reports may be less accurate

Impact of fatigue as the primary determinant of functional limitations among patients with post-COVID-19 syndrome: a cross-sectional observational study

OBJECTIVES: To describe self-reported characteristics and symptoms of treatment-seeking patients with post-COVID-19 syndrome (PCS). To assess the impact of symptoms on health-related quality of life (HRQoL) and patients' ability to work and undertake activities of daily living. DESIGN: Cross-sectional single-arm service evaluation of real-time user data. SETTING: 31 post-COVID-19 clinics in the UK. PARTICIPANTS: 3754 adults diagnosed with PCS in primary or secondary care deemed suitable for rehabilitation. INTERVENTION: Patients using the Living With Covid Recovery digital health intervention registered between 30 November 2020 and 23 March 2022. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the baseline Work and Social Adjustment Scale (WSAS). WSAS measures the functional limitations of the patient; scores of ≥20 indicate moderately severe limitations. Other symptoms explored included fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue), depression (Patient Health Questionnaire-Eight Item Depression Scale), anxiety (Generalised Anxiety Disorder Scale, Seven-Item), breathlessness (Medical Research Council Dyspnoea Scale and Dyspnoea-12), cognitive impairment (Perceived Deficits Questionnaire, Five-Item Version) and HRQoL (EQ-5D). Symptoms and demographic characteristics associated with more severe functional limitations were identified using logistic regression analysis. RESULTS: 3541 (94%) patients were of working age (18-65); mean age (SD) 48 (12) years; 1282 (71%) were female and 89% were white. 51% reported losing ≥1 days from work in the previous 4 weeks; 20% reported being unable to work at all. Mean WSAS score at baseline was 21 (SD 10) with 53% scoring ≥20. Factors associated with WSAS scores of ≥20 were high levels of fatigue, depression and cognitive impairment. Fatigue was found to be the main symptom contributing to a high WSAS score. CONCLUSION: A high proportion of this PCS treatment-seeking population was of working age with over half reporting moderately severe or worse functional limitation. There were substantial impacts on ability to work and activities of daily living in people with PCS. Clinical care and rehabilitation should address the management of fatigue as the dominant symptom explaining variation in functionality

Demonstration of the Effect of Generic Anatomical Divisions versus Clinical Protocols on Computed Tomography Dose Estimates and Risk Burden

Objective: Choosing to undertake a CT scan relies on balancing risk versus benefit, however risks associated with CT scanning have generally been limited to broad anatomical locations, which do not provided adequate information to evaluate risk against benefit. Our study aimed to determine differences in radiation dose and risk estimates associated with modern CT scanning examinations when computed for clinical protocols compared with those using anatomical area. Methods: Technical data were extracted from a tertiary hospital Picture Archiving Communication System for random samples of 20–40 CT examinations per adult clinical CT protocol. Organ and whole body radiation dose were calculated using ImPACT Monte Carlo simulation software and cancer incidence and mortality estimated using BEIR VII age and gender specific lifetime attributable risk weights. Results: Thirty four unique CT protocols were identified by our study. When grouped according to anatomic area the radiation dose varied substantially, particularly for abdominal protocols. The total estimated number of incident cancers and cancer related deaths using the mean dose of anatomical area were 86 and 69 respectively. Using more specific protocol doses the estimates rose to 214 and 138 incident cancers and cancer related deaths, at least doubling the burden estimated. Conclusions: Modern CT scanning produces a greater diversity of effective doses than much of the literature describes; where a lack of focus on actual scanning protocols has produced estimates that do not reflect the range and complexity of modern CT practice. To allow clinicians, patients and policy makers to make informed risk versus benefit decisions the individual and population level risks associated with modern CT practices are essential

Demographic and biologic influences on survival in whites and blacks: 40 years of follow-up in the Charleston heart study

BACKGROUND: In the United States, life expectancy is significantly lower among blacks than whites. We examined whether socioeconomic status (SES) and cardiovascular disease (CVD) risk factors may help explain this disparity. METHODS: Forty years (1961 through 2000) of all-cause mortality data were obtained on a population-based cohort of 2,283 subjects in the Charleston Heart Study (CHS). We examined the influence of SES and CVD risk factors on all-cause mortality. RESULTS: Complete data were available on 98% of the original sample (647 white men, 728 white women, 423 black men, and 443 black women). After adjusting for SES and CVD risk factors, the hazard ratios (HRs) for white ethnicity were 1.14 (0.98 to 1.32) among men and 0.90 (0.75 to 1.08) among women, indicating that the mortality risk was 14% greater for white men and 10% lower for white women compared to their black counterparts. However the differences were not statistically significant. CONCLUSION: While there are marked contrasts in mortality among blacks and whites in the CHS, the differences can be largely explained by SES and CVD risk factors. Continued focus on improving and controlling cardiovascular disease risk factors may reduce ethnic disparities in survival

The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom

Severe mental illness is a serious and potentially life changing set of conditions. This paper describes and analyses patient characteristics and service usage over one year of a representative cohort of people with a diagnosis of severe mental illness across England, including contacts with primary and secondary care and continuity of care

On the biomedicalization of alcoholism

The shift in the prevailing view of alcoholism from a moral paradigm towards a biomedical paradigm is often characterized as a form of biomedicalization. We will examine and critique three reasons offered for the claim that viewing alcoholism as a disease is morally problematic. The first is that the new conceptualization of alcoholism as a chronic brain disease will lead to individualization, e.g., a too narrow focus on the individual person, excluding cultural and social dimensions of alcoholism. The second claim is that biomedicalization will lead to stigmatization and discrimination for both alcoholics and people who are at risk of becoming alcoholics. The third claim is that as a result of the biomedical point of view, the autonomy and responsibility of alcoholics and possibly even persons at risk may be unjustly restricted. Our conclusion is that the claims against the biomedical conceptualization of alcoholism as a chronic brain disease are neither specific nor convincing. Not only do some of these concerns also apply to the traditional moral model; above that they are not strong enough to justify the rejection of the new biomedical model altogether. The focus in the scientific and public debate should not be on some massive “biomedicalization objection” but on the various concerns underlying what is framed in terms of the biomedicalization of alcoholism