How do HMOs Achieve Savings? The Effectiveness of One Organization\u27s Strategies.

To examine how a group practice used organizational strategies rather than provider-level incentives to achieve savings for health maintenance organization (HMO) compared to fee-for-service (FFS) patients. A large group practice with a group model HMO also treating FFS patients. Data sources were all patient encounter records, demographic files, and clinic records covering 3.5 years (1986-1989). The clinic\u27s procedures to record services and charges were identical for FFS and HMO patients. All FFS and HMO patients under age 65 who received any outpatient services during approximately 100,000 episodes of the seven study illnesses were eligible

Developing predictive models of health literacy.

IntroductionLow health literacy (LHL) remains a formidable barrier to improving health care quality and outcomes. Given the lack of precision of single demographic characteristics to predict health literacy, and the administrative burden and inability of existing health literacy measures to estimate health literacy at a population level, LHL is largely unaddressed in public health and clinical practice. To help overcome these limitations, we developed two models to estimate health literacy.MethodsWe analyzed data from the 2003 National Assessment of Adult Literacy (NAAL), using linear regression to predict mean health literacy scores and probit regression to predict the probability of an individual having 'above basic' proficiency. Predictors included gender, age, race/ethnicity, educational attainment, poverty status, marital status, language spoken in the home, metropolitan statistical area (MSA) and length of time in U.S.ResultsAll variables except MSA were statistically significant, with lower educational attainment being the strongest predictor. Our linear regression model and the probit model accounted for about 30% and 21% of the variance in health literacy scores, respectively, nearly twice as much as the variance accounted for by either education or poverty alone.ConclusionsMultivariable models permit a more accurate estimation of health literacy than single predictors. Further, such models can be applied to readily available administrative or census data to produce estimates of average health literacy and identify communities that would benefit most from appropriate, targeted interventions in the clinical setting to address poor quality care and outcomes related to LHL

The Stimulatory Potency of T Cell Antigens Is Influenced by the Formation of the Immunological Synapse

SummaryT cell activation is predicated on the interaction between the T cell receptor and peptide-major histocompatibility (pMHC) ligands. The factors that determine the stimulatory potency of a pMHC molecule remain unclear. We describe results showing that a peptide exhibiting many hallmarks of a weak agonist stimulates T cells to proliferate more than the wild-type agonist ligand. An in silico approach suggested that the inability to form the central supramolecular activation cluster (cSMAC) could underlie the increased proliferation. This conclusion was supported by experiments that showed that enhancing cSMAC formation reduced stimulatory capacity of the weak peptide. Our studies highlight the fact that a complex interplay of factors determines the quality of a T cell antigen

Challenges To Using A Business Case For Addressing Health Disparities

The authors consider the challenges to quantifying both the business case and the social case for addressing disparities, which is central to achieving equity in the U.S. health care system. They describe the practical and methodological challenges faced by health plans exploring the business and social cases for undertaking disparity-reducing interventions. Despite these challenges, sound business and quality improvement principles can guide health care organizations seeking to reduce disparities. Place-based interventions may help focus resources and engage health care and community partners who can share in the costs of—and gains from—such efforts

Measuring persistence of implementation: QUERI Series

As more quality improvement programs are implemented to achieve gains in performance, the need to evaluate their lasting effects has become increasingly evident. However, such long-term follow-up evaluations are scarce in healthcare implementation science, being largely relegated to the "need for further research" section of most project write-ups. This article explores the variety of conceptualizations of implementation sustainability, as well as behavioral and organizational factors that influence the maintenance of gains. It highlights the finer points of design considerations and draws on our own experiences with measuring sustainability, framed within the rich theoretical and empirical contributions of others. In addition, recommendations are made for designing sustainability analyses

Actualización en síndrome hemolítico urémico atípico: diagnóstico y tratamiento. Documento de consenso. Revisión

Podeu consultar la versió en castellà del document a: http://dx.doi.org/10.1016/j.nefro.2015.07.005Haemolytic uraemic syndrome (HUS) is a clinical entity defined as the triad of nonimmune haemolytic anaemia, thrombocytopenia, and acute renal failure, in which the underlying lesions are mediated by systemic thrombotic microangiopathy (TMA). Different causes can induce the TMA process that characterises HUS. In this document we consider atypical HUS (aHUS) a sub-type of HUS in which the TMA phenomena are the consequence of the endotelial damage in the microvasculature of the kidneys and other organs due to a disregulation of the activity of the complement system. In recent years, a variety of aHUs-related mutations have been identified in genes of the complement system, which can explain approximately 60% of the aHUS cases, and a number of mutations and polymorphisms have been functionally characterised. These findings have stablished that aHUS is a consequence of the insufficient regulation of the activation of the complement on cell surfaces, leading to endotelial damage mediated by C5 and the complement terminal pathway. Eculizumab is a monoclonal antibody that inhibits the activation of C5 and blocks the generation of the pro-inflammatory molecule C5a and the formation of the cell membrane attack complex. In prospective studies in patients with aHUS, the use of Eculizumab has shown a fast and sustained interruption of the TMA process and it has been associated with significative long-term improvements in renal function, the interruption of plasma therapy and important reductions in the need of dialysis. According to the existing literature and the accumulated clinical experience, the Spanish aHUS Group published a consensus document with recommendations for the treatment of aHUs (Nefrologia 2013;33[1]:27-45). In the current online version of this document, we update the aetiological classification of TMAs, the pathophysiology of aHUS, its differential diagnosis and its therapeutic management

Awareness in Practice: Tensions in Access to Sensitive Attribute Data for Antidiscrimination

Organizations cannot address demographic disparities that they cannot see. Recent research on machine learning and fairness has emphasized that awareness of sensitive attributes, such as race and sex, is critical to the development of interventions. However, on the ground, the existence of these data cannot be taken for granted. This paper uses the domains of employment, credit, and healthcare in the United States to surface conditions that have shaped the availability of sensitive attribute data. For each domain, we describe how and when private companies collect or infer sensitive attribute data for antidiscrimination purposes. An inconsistent story emerges: Some companies are required by law to collect sensitive attribute data, while others are prohibited from doing so. Still others, in the absence of legal mandates, have determined that collection and imputation of these data are appropriate to address disparities. This story has important implications for fairness research and its future applications. If companies that mediate access to life opportunities are unable or hesitant to collect or infer sensitive attribute data, then proposed techniques to detect and mitigate bias in machine learning models might never be implemented outside the lab. We conclude that today's legal requirements and corporate practices, while highly inconsistent across domains, offer lessons for how to approach the collection and inference of sensitive data in appropriate circumstances. We urge stakeholders, including machine learning practitioners, to actively help chart a path forward that takes both policy goals and technical needs into account

Synthesis, characterization, dynamics and reactivity toward amination of η3-allyl palladium complexes bearing mixed ancillary ligands. Evaluation of the electronic characteristics of the ligands from kinetic data.

On the basis of an original protocol, we have synthesized several complexes of the type [Pd(eta(3)-C(3)H(3)R(2))(LL')]ClO(4) (R = H, Me; L, L' = PPh(3), P(OEt)(3), 2,6-dimethylphenylisocyanide, t-butylisocyanide, 1,3-dimesitylimidazolidine, 1,3-dimesitylimidazol-2-ylidene). The complexes, some of which are completely new species, were fully characterized and their behaviour in solution was studied by means of (1)H NMR. The reactions of the complexes bearing the symmetric allyl moiety [Pd(eta(3)-C(3)H(5))(LL')]ClO(4) with piperidine in the presence of the olefin dimethylfumarate were followed under kinetically controlled conditions. Formation of allyl-amine and of the palladium(0) derivatives [Pd(eta(2)-dmfu)(LL'] was observed. The reaction rates k(2) proved to be strongly dependent on the ancillary ligand nature and allowed a direct comparison among the electronic characteristics of the ligands. The reactivity trend determined appears to be mainly influenced by the capability of the ancillary ligands in transferring electron density to the metal centre and consequently on the allyl fragment

Organizational and physician characteristics predicting practice style: A study of outpatient care in a large group practice

This dissertation examines the impact of non-clinical factors on physician practice styles in a large group practice. I compared the outpatient resources used for HMO vs. FFS patients during episodes of acute illness when the HMO and FFS patients being compared were treated by the same physicians. I also examined whether the setting--a free-standing branch clinic or the hospital-based main clinic--where physicians practiced lead to different styles of care. In both sets of analyses, I used extensive controls for clinical factors and a variety of non-clinical factors including physician specialty and organizational factors.The study site was one of the 15 largest group practices in the U.S., where 1/3 of the patients were HMO and 2/3 FFS--all treated by the same physicians. The claims data for the HMO and FFS patients were identical. I used an episode approach in which all care rendered during a specified period was recorded, along with who provided it and where it was provided. Seven diseases including ulcer, esophagitis, gastritis, bronchitis, otitis media, eczema and back pain were considered. Based on 3 and 1/2 years of billing records (1986-89), between 1,300 and 46,000 episodes for each disease were obtained. In addition, socio-demographic and health-related information about each patient and organizational and professional information about the physician was obtained. Separate linear regression models with adjustments for case-mix, physician specialty, and organizational factors were used to determine the effect of insurance status and practice location on 5 different measures of resource use including the number of visits, and expenses for clinical, laboratory, and radiology services, and total outpatient costs.The findings indicate that although clinical factors were the most powerful predictors of resource use, both patient insurance type and practice location were significant predictors of practice styles as well. The specific effects of insurance and practice location varied somewhat by disease and types of resources. However, in most instances resource use was lower for episodes involving HMO patients and especially for those treated by physicians located in branch clinics.U of I OnlyETDs are only available to UIUC Users without author permissio