Medicare Reimbursement for Total Joint Arthroplasty: The Driving Forces.

BACKGROUND: Total joint arthroplasty is a large and growing part of the U.S. Medicare budget, drawing attention to how much providers are paid for their services. The purpose of this study was to examine the variables that affect total joint arthroplasty reimbursement. Along with standard economic variables, we include unique health-care variables. Given the focus on value in the Affordable Care Act, the model examines the relationship of the quality of care to total joint arthroplasty reimbursement. We hoped to find that reimbursement patterns reward quality and reflect standard economic principles. METHODS: Multivariable regression was performed to identify variables that correlate with Medicare reimbursement for total joint arthroplasty. Inpatient charge or reimbursement data on Medicare reimbursements were available for 2,750 hospitals with at least 10 discharges for uncomplicated total joint arthroplasty from the Centers for Medicare & Medicaid Services (CMS) for fiscal year 2011. Reimbursement variability was examined by using the Dartmouth Atlas to group institutions into hospital referral regions and hospital service areas. Independent variables were taken from the Dartmouth Atlas, CMS, the WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) Rural Health Research Center, and the United States Census. RESULTS: There were 427,207 total joint arthroplasties identified, with a weighted mean reimbursement of $14,324.84 (range,$9,103 to $38,686). Nationally, the coefficient of variation for reimbursements was 0.19. The regression model accounted for 52.5% of reimbursement variation among providers. The total joint arthroplasty provider volume (p \u3c 0.001) and patient satisfaction (p \u3c 0.001) were negatively correlated with reimbursement. Government ownership of a hospital (p \u3c 0.001) and higher Medicare costs (p \u3c 0.001) correlated positively with reimbursement. CONCLUSIONS: Medicare reimbursements for total joint arthroplasty are highly variable. Greater reimbursement was associated with lower patient volume, lower patient satisfaction, a healthier patient population, and government ownership of a hospital. As value-based reimbursement provisions of the Affordable Care Act are implemented, there will be dramatic changes in total joint arthroplasty reimbursements. To meet these changes, providers should expect qualities such as high patient volume, willingness to care for sicker patient populations, patient satisfaction, safe outcomes, and procedural demand to correlate with their reimbursement. CLINICAL RELEVANCE: Practicing orthopaedic surgeons and hospital administrators should be aware of discrepancies in inpatient reimbursement for total joint arthroplasty from Medicare. Furthermore, these discrepancies are not associated with typical economic factors. These findings warrant further investigation and collaboration between policymakers and providers to develop value-based reimbursement

Components of the ubiquitin-proteasome pathway compete for surfaces on Rad23 family proteins

Background: The delivery of ubiquitinated proteins to the proteasome for degradation is a key step in the regulation of the ubiquitin-proteasome pathway, yet the mechanisms underlying this step are not understood in detail. The Rad23 family of proteins is known to bind ubiquitinated proteins through its two ubiquitin-associated (UBA) domains, and may participate in the delivery of ubiquitinated proteins to the proteasome through docking via the Rad23 ubiquitin-like (UBL) domain. Results: In this study, we investigate how the interaction between the UBL and UBA domains may modulate ubiquitin recognition and the delivery of ubiquitinated proteins to the proteasome by autoinhibition. We have explored a competitive binding model using specific mutations in the UBL domain. Disrupting the intramolecular UBL-UBA domain interactions in HHR23A indeed potentiates ubiquitin-binding. Additionally, the analogous surface on the Rad23 UBL domain overlaps with that required for interaction with both proteasomes and the ubiquitin ligase Ufd2. We have found that mutation of residues on this surface affects the ability of Rad23 to deliver ubiquitinated proteins to the proteasome. Conclusions: We conclude that the competition of ubiquitin-proteasome pathway components for surfaces on Rad23 is important for the role of the Rad23 family proteins in proteasomal targeting

Quantifying transport energy efficiency savings

The importance of quantifying energy savings and improvement in energy efficiency for each sector of the economy is now widely recognized in order to demonstrate progress towards targets and compliance with legal obligations. The focus of this paper is specifically on evaluating energy efficiency in transport using the ODEX methodology. More detailed data has recently become available on transport energy trends and the underlying factors that allow the authors improve the calculation of Ireland’s transport ODEX. Through data mining of administrative databases mileage, volume, age, engine type and size data are available at a disaggregated level for each mode of road transport. In particular this paper examines private car energy efficiency, quantifying the change arising from improved data. There was an overall slight improvement (0.71 percentage points) in the Irish private car ODEX when both proposed changes of using MJ/km as the unit consumption measure and modeling the stock by vintage were applied. The overall effect of the revised transport ODEX calculation does not show a significant increase in energy savings associated with the value of the ODEX indicator (0.82%). However the purpose was to improve the methodology of how the ODEX was being calculated, not necessarily increasing the savings

Darwin Tames an Andromeda Dwarf: Unraveling the Orbit of NGC 205 Using a Genetic Algorithm

NGC 205, a close satellite of the M31 galaxy, is our nearest example of a dwarf elliptical galaxy. Photometric and kinematic observations suggest that NGC 205 is undergoing tidal distortion from its interaction with M31. Despite earlier attempts, the orbit and progenitor properties of NGC 205 are not well known. We perform an optimized search for these unknowns by combining a genetic algorithm with restricted N-body simulations of the interaction. This approach, coupled with photometric and kinematic observations as constraints, allows for an effective exploration of the parameter space. We represent NGC 205 as a static Hernquist potential with embedded massless test particles that serve as tracers of surface brightness. We explore 3 distinct, initially stable configurations of test particles: cold rotating disk, warm rotating disk, and hot, pressure-supported spheroid. Each model reproduces some, but not all, of the observed features of NGC 205, leading us to speculate that a rotating progenitor with substantial pressure support could match all of the observables. Furthermore, plausible combinations of mass and scale length for the pressure-supported spheroid progenitor model reproduce the observed velocity dispersion profile. For all 3 models, orbits that best match the observables place the satellite 11+/-9 kpc behind M31 moving at very large velocities: 300-500 km/s on primarily radial orbits. Given that the observed radial component is only 54 km/s, this implies a large tangential motion for NGC 205, moving from the NW to the SE. These results suggest NGC 205 is not associated with the stellar arc observed to the NE of NGC 205. Furthermore, NGC 205's velocity appears to be near or greater than its escape velocity, signifying that the satellite is likely on its first M31 passage.Comment: 34 pages, 20 figures, accepted for publication in the Astrophysical Journal, A pdf version with high-resolution figures may be obtained from http://www.ucolick.org/~kirsten/ms.pd

A Cost Analysis of an Institutional Token Motivational System

48 leaves.The problem: An analysis was performed on the cost and effectiveness of a token motivational system in a state hospital. Procedure: A token economy program, designed and implemented by a multidisciplinary team, attempted to motivate 48 retarded residents to perform 27 self-help skills and 51 work tasks. Six weeks of residents' baseline performance was compared to the effects of eight weeks of treatment programming. Cost break-outs of the total treatment cost for direct and indirect treatment cost, three stages of program development and a comparison of the monthly ward cost with and without the treatment program were performed. Findings: The treatment program was effective in increasing the self-help and work behaviors. The various cost breakouts indicated that: (a) professional and non-professional time was reallocated cost to the system, (b) the only major additional cost to the system was supplies, (c) the dollar cost for operating a large number of projects was relatively small. Conclusion: A behavior modification program fulfills the requirements for a Program-Planning-Budgeting-System analysis and makes possible an evaluation of the cost and effectiveness of a residential treatment program. Recommendations: Future research should be directed toward developing more useful empirical cost data collection procedures

The SPLASH Survey: Kinematics of Andromeda's Inner Spheroid

The combination of large size, high stellar density, high metallicity, and Sersic surface brightness profile of the spheroidal component of the Andromeda galaxy (M31) within R_proj ~ 20 kpc suggest that it is unlike any subcomponent of the Milky Way. In this work we capitalize on our proximity to and external view of M31 to probe the kinematical properties of this "inner spheroid." We employ a Markov chain Monte Carlo (MCMC) analysis of resolved stellar kinematics from Keck/DEIMOS spectra of 5651 red giant branch stars to disentangle M31's inner spheroid from its stellar disk. We measure the mean velocity and dispersion of the spheroid in each of five spatial bins after accounting for a locally cold stellar disk as well as the Giant Southern Stream and associated tidal debris. For the first time, we detect significant spheroid rotation (v_rot ~ 50 km/s) beyond R_proj ~ 5 kpc. The velocity dispersion decreases from about 140 km/s at R_proj = 7 kpc to 120 km/s at R_proj = 14 kpc, consistent to 2 sigma with existing measurements and models. We calculate the probability that a given star is a member of the spheroid and find that the spheroid has a significant presence throughout the spatial extent of our sample. Lastly, we show that the flattening of the spheroid is due to velocity anisotropy in addition to rotation. Though this suggests that the inner spheroid of M31 more closely resembles an elliptical galaxy than a typical spiral galaxy bulge, it should be cautioned that our measurements are much farther out (2 - 14 r_eff) than for the comparison samples.Comment: Accepted for publication in Ap

Lettuce be happy: A longitudinal UK study on the relationship between fruit and vegetable consumption and well-being

Rationale: While the role of diet in influencing physical health is now well-established, some recent research suggests that increased consumption of fruits and vegetables could play a role in enhancing mental well-being. A limitation with much of this existing research is its reliance on cross-sectional correlations, convenience samples, and/or lack of adequate controls. Objective: We aim to add to the emerging literature on the relationship between fruit and vegetable consumption and well-being by using longitudinal data from a study in the United Kingdom (UK). Method: We employ panel data analytical techniques on three waves collected between 2010 and 2017 (i.e., following the same individuals over time) in the UK Household Longitudinal Survey. We also control for time-variant confounders such as diet, health, and lifestyle behaviours. Results: Fixed effects regressions show that mental well-being (GHQ-12) responds in a dose-response fashion to increases in both the quantity and the frequency of fruit and vegetables consumed. This relationship is robust to the use of subjective well-being (life satisfaction) instead of mental well-being. We also document a hump-shaped relationship between fruit and vegetable consumption and age. Conclusion: Our findings provide further evidence that persuading people to consume more fruits and vegetables may not only benefit their physical health in the long-run, but also their mental well-being in the short-run

Can re-entrance be observed in force induced transitions?

A large conformational change in the reaction co-ordinate and the role of the solvent in the formation of base-pairing are combined to settle a long standing issue {\it i.e.} prediction of re-entrance in the force induced transition of DNA. A direct way to observe the re-entrance, i.e a strand goes to the closed state from the open state and again to the open state with temperature, appears difficult to be achieved in the laboratory. An experimental protocol (in direct way) in the constant force ensemble is being proposed for the first time that will enable the observation of the re-entrance behavior in the force-temperature plane. Our exact results for small oligonucleotide that forms a hairpin structure provide the evidence that re-entrance can be observed.Comment: 12 pages and 5 figures (RevTex4). Accepted in Europhys Lett. (2009