Neural mechanisms in abomasal motility

1. The motor profile of the exteriorized abomasal body and antrum of chloralose-anaesthetized adult sheep, recorded using balloon catheters and e.m.g. electrodes, consisted of tonic muscular activity upon which contractile muscular activity could be superimposed. The different motility patterns of the body and antrum suggest that they are separate functional entities.2. Transection of the exteriorized abomasum into separate body and antral pouches significantly increased antral contraction amplitude and significantly decreased body tone. This suggests that in the intact preparation the body exerts an intrinsic inhibitory drive to antral contraction amplitude, and that either the antrum exerts an intrinsic excitatory drive to body tone or increased antral contraction amplitude results in an extrinsic inhibitory drive to body tone.3. Repetitive electrical stimulation of the cut peripheral end of the cervical vagus ( 1-10 Hz, 1-50 V, 1 ms pulse duration for 10 s) caused body relaxation in 5 out of 7 preparations. Higher frequency electrical stimulation (10— 50 Hz) caused body contraction. In 4 preparations electrical stimulation (1-50 Hz, 1-50 V, 1 ms pulse duration for 10 s) of the cut peripheral end of the cervical vagus caused antral contraction. In 3 ostensibly identical preparations similar electrical stimulation reduced antral contraction amplitude. Thus evidence was found for vagal excitatory and inhibitory innervation of the abomasal body and antrum, and for an integrative mechanism at the intramural level.4. Body pouch inflation increased antral contraction amplitude by a vagally-dependent mechanism, and decreased the discharge rate of 10 out of 33 efferent units isolated from abdominal branches of the vagus within 2 cm of the antrum. If the decrease in unitary discharge is instrumental in increasing antral contraction amplitude it is likely that the units have inhibitory function.5. The slight body pouch relaxation produced by body pouch inflation was not altered by extrinsic denervation. Inflation of an intra-reticular balloon produced similar effects on the abomasal body motor profile as inflation to the same volume of an intra-abdominal balloon placed beside the reticulum. Thus no evidence was found for a functional reflex corresponding to receptive relaxation found in the monogastric animal.6. The response of 33 efferent units, dissected from the abdominal continuations of the dorsal and ventral vagi within 2 cm of the antrum, to inflation of the abomasal body pouch, and to systemic injection of 100 ug of adrenaline was investigated. All units responding to body pouch inflation also responded to adrenaline injection. Unitary discharge was analysed for temporal relationships with antral e.m.g. activity and the e.c.g. using a post stimulus time histogram technique. Units showing discharge association with the antral e.m.g. also showed discharge association with the e.c.g. Thus in the sheep neither discharge response to discrete stimulation of specific receptor populations nor the presence of system-related rhythms in efferent discharge is necessarily indicative of efferent destination or function

Optimal hospital payment rules under rationing by waiting

We derive optimal rules for paying hospitals for non-emergency care when providers choose quality and capacity, and patient demand is rationed by waiting time. Waiting for treatment is costly for patients, so that hospital payment rules should take account of their effect on waiting time as well as on quality. Since deterministic waiting time models imply that profit maximising hospitals will never choose to have both positive quality and positive waiting time, we develop a stochastic model of rationing by waiting in which both quality and expected waiting are positive in equilibrium. We use it to show that, although a prospective output price gives hospitals an incentive to attract patients by raising quality and reducing waiting times, it must be supplemented by a price attached to hospital decisions on quality or capacity or to a performance indicator which depends on those decisions (such as average waiting time, or average length of stay). A prospective output price by itself can support the optimal quality and waiting time distribution only if the welfare function respects patient preferences over quality and waiting time, if patients' marginal rates of substitution between quality and waiting time are independent of income, and if waiting for treatment does not reduce the productivity of patients. If these conditions do not hold, supplementing the output price with a reward linked to the hospital's cost can increase welfare, though it is possible that costs should be taxed rather than subsidised

Patterns of emergency admissions for ambulatory care sensitive conditions: : a spatial cross-sectional analysis of observational data

Objectives: To examine the spatial and temporal patterns of English general practices’ emergency admissions for Ambulatory Care Sensitive Conditions (ACSC). Design: Observational study of annual hospital admission data for ACSC emergency admissions at general practice level for all practices in England 2004 to 2017. Participants: All patients with an emergency admission to a National Health Service (NHS) hospital in England who were registered with an English GP practice. Main outcome measure: Practice level age and gender indirectly standardised ratios (ISARs) for emergency admissions for ACSC. Results: In 2017 41.8% of the total variation in ISARs across practices was between the 207 Clinical Commissioning Groups (the administrative unit for general practices) and 58.2% was across practices within CCGs. ACSC ISARs increased by 4.7% between 2004 and 2017 while those for conditions incentivised by the Quality and Outcomes Framework fell by 20.02%. Practice ISARs are persistent: practices with high rates in 2004 also had high rates in 2017. Standardising by deprivation as well as age and gender reduced the coefficient of variation of practice ISARs in 2017 by 22% Conclusions: There is persistent spatial pattern of emergency admissions for ACSC across England both within and across CCGs. We illustrate the reduction in ACSC emergency admissions across the study period for conditions incentivised by the QOF but find that this was not accompanied by a reduction in variation in these admissions across practices. The observed spatial pattern persists when admission rates are standardised by deprivation. The persistence of spatial clusters of high emergency admissions for ACSC within and across CCG boundaries suggests that policies to reduce potentially unwarranted variation should be targeted at practice level

Interprofessional collaboration within teams comprised of health and other professionals: a systematic review of measurement tools and their psychometric properties

Background and Purpose: Measuring collaboration within interprofessional teams allows professionals to evaluate their practice, set benchmarks and improve outcomes. In the context of healthcare, most research has focused on teams comprised solely of health professionals, with limited attention given to collaboration between health and other professionals. Given the escalating complexities of healthcare, and the growing need for interprofessional collaborative practice involving team members external to health care, this represents a considerable gap in the literature. Therefore, the purpose of this review was to identify tools that measure collaboration within interprofessional teams comprised of members from health and other disciplines, and evaluate their psychometric properties. This review focused on the area of children’s services, to assist professionals working in this area with their collaborative practice. Methods: A systematic search including nineteen electronic databases was conducted. Eleven articles (describing ten tools) were identified for inclusion and were critically appraised. Results: Overall, it was found that few psychometrically sound tools exist for more diverse professional groups working together. The PINCOM-Q was found to be the most appropriate tool for the context of children’s services, and with the highest critical appraisal score, as reported. Conclusions: Recommendations are made for further development of existing tools before practical implementation. Further research could develop new and innovative tools to accommodate the evolving composition of future interprofessional teams

Long-term care provision, hospital bed blocking, and discharge destination for hip fracture and stroke patients

We examine the relationship between long-term care supply (care-home beds and prices) and (i) the probability of being discharged to a care home and (ii) length of stay in hospital for patients admitted to hospital for hip fracture or stroke. Using patient level data from all English hospitals and allowing for a rich set of demographic and clinical factors, we find no association between discharge destination and long term care beds supply or prices. We do, however, find evidence of bed blocking: hospital length of stay for hip fracture patients discharged to a care home is shorter in areas with more long-term care beds and lower prices. Length of stay is over 30% shorter in areas in the highest quintile of care home beds supply compared to those in the lowest quintile

Book Reviews

Securities Legislation By Louis Loss Boston: Little, Brown & Com-pany, 1951. Pp. xxvii, 1283. $17.50 reviewer: Hugh L. Sowards ================================ Private Property, the History of an Idea By Richard Schlatter New Brunswick: Rutgers University Press, 1951. Pp. 284.$2.50 reviewer: Stanley D. Rose ================================== Oil and Gas Law: Collection of articles TEXAS LAW REVIEW Austin: Texas Law Review, Inc., 1951. Pp. xix, 1736. $15.00 reviewer: William D. Warre

Optimal hospital payment rules under rationing by random waiting

We derive optimal rules for paying hospitals in a public health care system in which providers can choose quality and random patient demand is rationed by waiting time. Since waiting time imposes real costs on patients hospital payment rules should take account of their effect on waiting time as well as on quality and the number of patients treated. We develop a general stochastic model of rationing by waiting and use it to derive welfare maximising payment to hospitals linked to output, expected waiting times, quality, hospital capacity and length of stay. We show that, although prospective output pricing gives hospitals an incentive to attract patients by raising quality and reducing waiting times, it must be supplemented by prices attached to other hospital decisions and outcomes except under very strong assumptions about the welfare function, patient preferences, and whether patients lose income whilst waitin