Medicare Payment Reform: Aligning Incentives for Better Care

The Affordable Care Act (ACA) has provided the Medicare program with an array of tools to improve the quality of care that beneficiaries receive and to increase the efficiency with which that care is provided. Notably, the ACA has created the Center for Medicare and Medicaid Innovation, which is developing and testing promising new models to improve the quality of care provided to Medicare beneficiaries while reducing spending. These new models are part of an effort by the U.S. Department of Health and Human Services to increase the proportion of traditional Medicare payments tied to quality or value to 85 percent by 2016 and 90 percent by 2018. This issue brief, one in a series on Medicare's past, present, and future, explores the evolution of Medicare payment policy, the potential of value-based payment to improve care for beneficiaries and achieve savings, and strategies for accelerating its adoption

Oral Health Disparities and Unmet Dental Needs among Preschool Children in Chelsea, MA: Exploring Mechanisms, Defining Solutions

Background: Significant disparities exist in children’s receipt of preventive dental care (PDC) in the United States. Many of the children at greatest risk of dental disease do not receive timely PDC; when they do receive dental care, it is often more for relief of dental pain. Chelsea is a low-income, diverse Massachusetts community with high rates of untreated childhood caries. There are various dental resources available in Chelsea, yet many children do not access dental care at levels equivalent to their needs. Objective: Using Chelsea as a case-study, to explore factors contributing to forgone PDC (including the age 1 dental visit) in an in-depth way. Methods: We used a qualitative study design that included semi-structured interviews with parents of preschool children residing in Chelsea, and Chelsea-based providers including pediatricians, dentists, a dental hygienist and early childhood care providers. We examined: a) parents’ dental attitudes and oral health cultural beliefs; b) parents’ and providers’ perspectives on facilitators and barriers to PDC, reasons for unmet needs, and proposed solutions to address the problem. We recorded, transcribed and independently coded all interviews. Using rigorous, iterative qualitative data analyses procedures, we identified emergent themes. Results: Factors perceived to facilitate receipt of PDC included Head-Start oral health policies, strong pediatric primary care/dental linkages, community outreach and advertising, and parents’ own oral health experiences. Most parents and providers perceived there to be an adequate number of accessible dental services and resources in Chelsea, including for Medicaid enrollees. However, several barriers impeded children from receiving timely PDC, the most frequently cited being insurance related problems for children and adults. Other barriers included limited dental services for children <2 years, perceived poor quality of some dental practices, lack of emphasis on prevention-based dental care, poor care-coordination, and insufficient culturally-appropriate care. Important family-level barriers included parental oral health literacy, cultural factors, limited English proficiency and competing priorities. Several solutions were proposed to address identified barriers. Conclusion: Even in a community with a considerable number of dental resources, various factors may preclude access to these services by preschool-aged children. Opportunities exist to address modifiable factors through strategic oral health policies, community outreach and improved care coordination between physicians, dentists and early childhood care providers

Relationship between continuity of care and adverse outcomes varies by number of chronic conditions among older adults with diabetes

Background: Continuity of care is a basic tenant of primary care practice. However, the evidence on the importance of continuity of care for older adults with complex conditions is mixed. Objective: To assess the relationship between measurement of continuity of care, number of chronic conditions, and health outcomes. Design: We analyzed data from a cohort of 1,600 US older adults with diabetes and ≥1 other chronic condition in a private Medicare health plan from July 2010 to December 2011. Multivariate regression models were used to examine the association of baseline continuity (the first 6 months) and the composite outcome of any emergency room use or inpatient hospitalization occurring in the following 12-month period. Results: After adjusting for baseline covariates, high known provider continuity (KPC) was associated with an 84% (adjusted odds ratio 0.16; 95% confidence interval 0.09–0.26) reduction in the risk of the composite outcome. High KPC was significantly associated with a lower risk of the composite outcome among individuals with ≥6 conditions. However, the usual provider of care and continuity of care indices were not significantly related with the composite outcome in the overall sample or in those with ≥6 conditions. Conclusion: The relationship between continuity of care and adverse outcomes depends on the measure of continuity of care employed. High morbidity patients are more likely to benefit from continuity of care interventions as measured by the KPC, which measures the proportion of a patient’s visits that are with the same providers over time. Journal of Comorbidity 2016;6(2):65–7

Spying and Surveillance in Shakespeare’s Dramatic Courts

This thesis examines representations of spying and surveillance in Shakespearean drama in conjunction with historical practices of espionage in later sixteenth-century England. The introductory chapter outlines how spying operations were conducted in Elizabethan England, with specific attention to the complex attitudes and behaviour of individual agents working in the broader context of the religious wars, both hot and cold, taking place between Protestant England and the Catholic powers of continental Europe. It also provides some analysis of the organisational structures within which those agents worked and examines a wide range of particular cases to illustrate how surveillance operations might play out in practice. The memory of Sir Francis Walsingham, often described as the ‘spymaster’ of Elizabeth’s government and noted for his skill in intelligence work, would have loomed large for any dramatist thinking about espionage at the turn of the seventeenth century. Subsequent chapters each examine a specific play in light of the material presented in the introduction, comprising Much Ado About Nothing, The Tempest, Measure for Measure, Henry V and Hamlet. Each chapter seeks to elucidate how Shakespeare draws upon the world of Elizabethan espionage to provide vital structural components in his dramatic plotting, especially as regards inter-personal relationships between courtiers, secretaries and agents on the ground. Real individuals and the spies depicted in Shakespeare’s plays all behave in a manner that is personally inflected to a profound degree, and it is this particular aspect of early-modern espionage that provides the single most important connection between history and drama. Periodically, this thesis also reflects upon the metatheatrical relationship between characters’ schemes and Shakespeare’s own plotting as a dramatist

6-OHDA generated ROS induces DNA damage and p53- and PUMA-dependent cell death

<p>Abstract</p> <p>Background</p> <p>Parkinson's disease (PD) is characterized by the selective loss of dopaminergic neurons in the substantia nigra (SN), resulting in tremor, rigidity, and bradykinesia. Although the etiology is unknown, insight into the disease process comes from the dopamine (DA) derivative, 6-hydroxydopamine (6-OHDA), which produces PD-like symptoms. Studies show that 6-OHDA activates stress pathways, such as the unfolded protein response (UPR), triggers mitochondrial release of cytochrome-c, and activates caspases, such as caspase-3. Because the BH3-only protein, Puma (p53-upregulated mediator of apoptosis), is activated in response to UPR, it is thought to be a link between cell stress and apoptosis.</p> <p>Results</p> <p>To test the hypothesis that Puma serves such a role in 6-OHDA-mediated cell death, we compared the response of dopaminergic neurons from wild-type and <it>Puma</it>-null mice to 6-OHDA. Results indicate that Puma is required for 6-OHDA-induced cell death, in primary dissociated midbrain cultures as well as <it>in vivo</it>. In these cultures, 6-OHDA-induced DNA damage and p53 were required for 6-OHDA-induced cell death. In contrast, while 6-OHDA led to upregulation of UPR markers, loss of ATF3 did not protect against 6-OHDA.</p> <p>Conclusions</p> <p>Together, our results indicate that 6-OHDA-induced upregulation of <it>Puma </it>and cell death are independent of UPR. Instead, p53 and DNA damage repair pathways mediate 6-OHDA-induced toxicity.</p

Prenatal maternal stress and risk of neurodevelopmental disorders in the offspring: A systematic review and meta-analysis protocol

Background: Prenatal maternal stress (PNMS) is defined as the experience of significant levels of prenatal stress, depression or anxiety during pregnancy. PNMS has been associated with increased risk of autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in exposed offspring. However, these findings are inconsistent and other studies found no association, meaning a clear consensus on the impact of PNMS on ASD and ADHD risk is required. The purpose of this systematic review and meta-analysis is to summarize and critically review the existing literature on the effects of PNMS on ASD and ADHD risk. Methods: Electronic databases (PubMed, PsycINFO, Web of Science, Scopus and EMBASE) will be searched for articles following a detailed search strategy. We will include cohort and case-control studies that assessed maternal exposure to psychological and/or environmental stress and had ASD or ADHD as an outcome. Two reviewers will independently screen the titles, abstracts and full articles to identify eligible studies. We will use a standardised data extraction form for extracting data and a bias classification tool for assessing study quality. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The generic inverse variance method will be used if possible to perform meta-analyses. Ethics and dissemination: Ethical approval is not required for this study because it will not involve the conduct or inclusion of any experimental or personal data that would require informed consent. The systematic review will be disseminated in peer-reviewed journals. PROSPERO registration number: CRD42018084222