Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences

Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients—those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs—those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks—to all adults and to those with multiple chronic diseases but no functional limitations. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey. Key findings: High-need adults were more likely to report having an unmet medical need and less likely to report having good patient–provider communication. High-need adults reported roughly similar ease of obtaining specialist referrals as other adults and greater likelihood of having a medical home. While adults with private health insurance reported the fewest unmet needs overall, privately insured highneed adults reported the greatest difficulties having their needs met. Conclusion: The health care system needs to work better for the highest-need, most-complex patients. This study's findings highlight the importance of tailoring interventions to address their need

Distribution and biological role of the oligopeptide-binding protein (OppA) in Xanthomonas species

In this study we investigated the prevalence of the oppA gene, encoding the oligopeptide binding protein (OppA) of the major bacterial oligopeptide uptake system (Opp), in different species of the genus Xanthomonas. The oppA gene was detected in two Xanthomonas axonopodis strains among eight tested Xanthomonas species. The generation of an isogenic oppA-knockout derivative of the Xac 306 strain, showed that the OppA protein neither plays a relevant role in oligopeptide uptake nor contributes to the infectivity and multiplication of the bacterial strain in leaves of sweet orange (Citrus sinensis) and Rangpur lime (Citrus limonia). Taken together these results suggest that the oppA gene has a recent evolutionary history in the genus and does not contribute in the physiology or pathogenesis of X. axonopodis

Transcriptome dynamics of a broad host-range cyanophage and its hosts

Cyanobacteria are highly abundant in the oceans and are constantly exposed to lytic viruses. The T4-like cyanomyoviruses are abundant in the marine environment and have broad host-ranges relative to other cyanophages. It is currently unknown whether broad host-range phages specifically tailor their infection program for each host, or employ the same program irrespective of the host infected. Also unknown is how different hosts respond to infection by the same phage. Here we used microarray and RNA-seq analyses to investigate the interaction between the Syn9 T4-like cyanophage and three phylogenetically, ecologically and genomically distinct marine Synechococcus strains: WH7803, WH8102 and WH8109. Strikingly, Syn9 led a nearly identical infection and transcriptional program in all three hosts. Different to previous assumptions for T4-like cyanophages, three temporally regulated gene expression classes were observed. Furthermore, a novel regulatory element controlled early-gene transcription, and host-like promoters drove middle gene transcription, different to the regulatory paradigm for T4. Similar results were found for the P-TIM40 phage during infection of Prochlorococcus NATL2A. Moreover, genomic and metagenomic analyses indicate that these regulatory elements are abundant and conserved among T4-like cyanophages. In contrast to the near-identical transcriptional program employed by Syn9, host responses to infection involved host-specific genes primarily located in hypervariable genomic islands, substantiating islands as a major axis of phage-cyanobacteria interactions. Our findings suggest that the ability of broad host-range phages to infect multiple hosts is more likely dependent on the effectiveness of host defense strategies than on differential tailoring of the infection process by the phage

A SARS-CoV-2 protein interaction map reveals targets for drug repurposing

The novel coronavirus SARS-CoV-2, the causative agent of COVID-19 respiratory disease, has infected over 2.3 million people, killed over 160,000, and caused worldwide social and economic disruption1,2. There are currently no antiviral drugs with proven clinical efficacy, nor are there vaccines for its prevention, and these efforts are hampered by limited knowledge of the molecular details of SARS-CoV-2 infection. To address this, we cloned, tagged and expressed 26 of the 29 SARS-CoV-2 proteins in human cells and identified the human proteins physically associated with each using affinity-purification mass spectrometry (AP-MS), identifying 332 high-confidence SARS-CoV-2-human protein-protein interactions (PPIs). Among these, we identify 66 druggable human proteins or host factors targeted by 69 compounds (29 FDA-approved drugs, 12 drugs in clinical trials, and 28 preclinical compounds). Screening a subset of these in multiple viral assays identified two sets of pharmacological agents that displayed antiviral activity: inhibitors of mRNA translation and predicted regulators of the Sigma1 and Sigma2 receptors. Further studies of these host factor targeting agents, including their combination with drugs that directly target viral enzymes, could lead to a therapeutic regimen to treat COVID-19

DOES THE PATIENT CENTERED MEDICAL HOME IMPROVE THE CARE FOR THE HIGH NEED, HIGH COST POPULATION?

Background: The patient-centered medical home (PCMH) has been proposed as a transformative model of delivery of health care that aims to improve health outcomes and lower health spending by providing care that is patient centered, comprehensive, coordinated, accessible and focused on quality and safety. Although PCMH is rapidly becoming widespread, there is mixed evidence on the effectiveness of current medical homes in delivering any or all of these objectives. There is disagreement as to whether this model is intended to improve care for all or should be targeted only at patients with high medical needs. However, recent findings are identifying benefits among subgroups with chronic conditions. Studies are also finding that care for mental health conditions is not commensurate with care for physical conditions in the PCMH. Individuals with multiple chronic conditions and those with comorbid depression are among the most medically needy and costliest patients. In addition, the role of payment reform in PCMH is understudied. This dissertation evaluates how adults with multiple chronic conditions and co-morbid depression respond to a specific PCMH intervention with two methods of reimbursement; fee-for-service and partial capitation. Methods: Administrative medical and pharmacy claims from a single commercial payer in the Albany and upstate New York areas for the years 2008 – 2013 are used. A segmented, interrupted time series design with individual level data clustered at the PCP level, with matched practice-level controls, was used to assess the effect of the transformation to PCMH of 22 practices recognized as NCQA Level 3, and the subsequent adoption of partial capitation of 13 of those practices. Outcomes include total medical, inpatient, ambulatory and drug expenditures as well as inpatient, emergency department, and office visit utilization. Results: PCMH affects subgroups with multiple chronic conditions. Payment through partial capitation increased access to ambulatory services and drugs while reducing the expenditures among those who used these services. PCMH continuing to remain on FFS had no effect among patients with co-morbid depression whereas PCMH with partial capitation has significant effects on ambulatory and drug expenditures. Conclusions: This study finds that PCMH affects outcomes for those with multiple chronic conditions. Further innovations in care need to be implemented in the PCMH to address the subgroup of patients with multiple chronic conditions with co-morbid depression. Payment reform is critical for the success of PCMH

Simulation Suggests that medical group mergers won't undermine the potential utility of health information exchanges.

Item does not contain fulltextFederal and state agencies are investing substantial resources in the creation of community health information exchanges, which are consortia that enable independent health care organizations to exchange clinical data. However, under pressure to form accountable care organizations, medical groups may merge and support private health information exchanges. Such activity could reduce the potential utility of community exchanges-that is, the exchanges' capacity to share patient data across hospitals and physician practices that are independent. Simulations of care transitions based on data from ten Massachusetts communities suggest that there would have to be many such mergers to undermine the potential utility of health information exchanges. At the same time, because hospitals and the largest medical groups account for only 10-20 percent of care transitions in a community, information exchanges will still need to recruit a large proportion of the medical groups in a given community for the exchanges to maintain their usefulness in fostering information exchange across independent providers.1 maart 201