Understanding the Role of the Patient-Centered Medical Home is Building a Strong Primary Care Foundation in the U.S.

It is generally agreed that there is much room for improvement in the U.S. healthcare system. In international comparisons, health care in the U.S. is consistently the most expensive and the U.S. lags other western industrialized countries in broad measures of health, such as morbidity and mortality. The Triple Aim goals for the improvement of U.S. healthcare outlined by the Institute for Healthcare Improvement (IHI) in 2008 continue to be widely embraced today – to improve the experience of care, improve the health of populations and to lower the per capita cost of care. To achieve these aims, the need for an “integrator” accountable for the achievement of all three aims on behalf of a defined population was recommended. One of the primary roles of the integrator is the redesign of primary care. Primary Care has long been regarded as a critical component of improving the healthcare system. In recent years, the Patient-Centered Medical Home (Medical Home) has been the favored model to return primary care to a more prominent and impactful role in the overall health care system. Using data from a commercial health plan Medical Home program in a regional geographic setting, this dissertation provides insights into the role and impact of the Medical Home in fulfilling the aspirational goals for U.S. primary care. This study examined basic differences between Medical Home and non-Medical Home practices, whether Medical Home implementation is associated with differences in physician practice patterns, and whether ownership of Medical Homes by hospitals or healthcare systems is associated with differences in total cost of care or the utilization of high-cost services. This study finds that small, rural primary care practices are under-represented among Medical Homes, that physicians practicing in Medical Homes provide care that is more consistent with high quality primary care than physicians practicing in non-Medical Homes, and that Medical Homes owned by hospitals or healthcare systems are associated with a higher total cost of care and higher rates of inpatient hospital admissions. The focus on the Medical Home model has provided an important vehicle for the evolution of primary care over the last ten years. It is an opportune time in this ongoing evolution for policy makers, health plans and healthcare purchasers to shift the conversation from a focus on the Medical Home to how to support high quality primary care in a consistent and sustainable manner across all primary care practices, regardless of practice size, geography, or ownership. Payers, including government purchasers and commercial health plans, are uniquely positioned to support this shift in the form of the “integrator” described as necessary to the fulfillment of the Triple Aim goals

Incidence of the retail sales tax as applied to Oklahoma.

The incidence, or distributional effect, of the retail sales tax has long been a concern of both economists and state legislators. Because the sales tax is added to consumer expenditures, and because households with lower incomes spend a larger proportion of their total income on consumption, as compared to households with higher incomes, the sales tax has been labeled a regressive tax. The purpose of this study is to examine the incidence of the retail sales tax in Oklahoma, using recent incidence theories, as well as regional modifications of the traditional method.The survey of retail sales tax incidence theory includes the development of general and partial equilibrium models, and presents the hypothesis allocating burden on the sources, as opposed to the uses, side of the income equation. An expanded measure of household income is developed for use as the incidence base, and the burden of Oklahoma's retail sales tax is expressed using various allocation methods and shifting assumptions. Actual published information for Oklahoma and interpolation of regional data provide the statistics used for the comparative analysis. The effect of the federal offset, since sales taxes can be deducted from federal income tax, and the portion of sales taxes paid by businesses, rather than consumers, influence the actual burden of the sales tax. It is concluded that the present sales tax in Oklahoma is indeed regressive, but not to the extent, either in real or proportional terms, generally assumed

Assessment of Technologies for the Space Shuttle External Tank Thermal Protection System and Recommendations for Technology Improvement - Part III: Material Property Characterization, Analysis, and Test Methods

The objective of this report is to contribute to the independent assessment of the Space Shuttle External Tank Foam Material. This report specifically addresses material modeling, characterization testing, data reduction methods, and data pedigree. A brief description of the External Tank foam materials, locations, and standard failure modes is provided to develop suitable background information. A review of mechanics based analysis methods from the open literature is used to provide an assessment of the state-of-the-art in material modeling of closed cell foams. Further, this report assesses the existing material property database and investigates sources of material property variability. The report presents identified deficiencies in testing methods and procedures, recommendations for additional testing as required, identification of near-term improvements that should be pursued, and long-term capabilities or enhancements that should be developed

Antecedents of New Director Social Capital

Prior research shows that firms benefit from the social capital of their boards of directors but has not explored the antecedents of new director social capital. We argue that firms can attract directors with social capital by offering more compensation. We also argue that more complex firms (firms with a greater scale and scope of operations) are more attractive to such directors because of the greater experience and exposure that such directorships provide. Similarly, we argue that firms with high-status directors on their current boards will be more attractive to directors with social capital. We analyse the social capital of new outside directors added to boards of semiconductor firms between 1993 and 2007. Surprisingly, we find no support for the hypothesis that higher compensation is associated with adding directors with high status or board ties. However, firm complexity is associated with the ability to add new directors who have social capital, and the status of current board members is associated with the ability to add new directors who also have high status

Perinatal stroke and the risk of developing childhood epilepsy

Objectives—To describe the prevalence of epilepsy after 6 months-of-age in children with perinatal stroke and examine whether perinatal data predict epilepsy onset and resolution. Study design—A retrospective review of 64 children with perinatal stroke. In children with at least 6 months of follow-up data, Kaplan-Meier curves, univariate log-rank tests, and Cox proportional hazards models were used to examine predictors of time to development of seizures, and time to resolution of seizures in children with epilepsy. The association of risk factors with the presence of epilepsy at any time after 6 months-of-age was examined using Fisher’s exact test. Results—Forty-one of the 61 children with at least 6 months of follow-up data (67%) had epilepsy between 6 months-of-age and last follow-up, but in 13 of 41 seizures eventually resolved and anticonvulsants were discontinued. Infarct on prenatal ultrasound (p=0.0065) and family history of epilepsy (p=0.0093) were significantly associated with time to development of seizures after 6 months-of-age in the univariate analysis. No assessed variables were associated with time to resolution of epilepsy or with the presence of epilepsy after 6 months-of-age. Conclusions—Childhood epilepsy is frequent after perinatal stroke. Evidence of infarction on prenatal ultrasound and a family history of epilepsy predict earlier onset of active seizures

Lesbian, gay, and bisexual college student experiences: An exploratory study

The current status of higher education research on lesbian, gay, and bisexual (LGB) students offers an incomplete picture of their overall college experiences. This study is a secondary analysis of data collected for the 2004 National Study of Living-Learning Programs. Data were collected from 34 universities in 24 states and the District of Columbia. The total sample selected included 71,728 students, of which 23,910 responded to the survey, resulting in a response rate of approximately 33.3%. The demographic characteristics of the sample of lesbian, gay, bisexual and heterosexual students were remarkably similar. The results of this exploratory study reveal a rich and multifaceted portrait of the LGB college experience. The results from this study indicate that lesbian and gay students perceive higher growth in critical thinking and liberal learning. of the presence of out LGB students. This study offers a rare glimpse into the overall college experience of lesbian, gay, and bisexual students, and it was made possible by including one question item about respondents' sexual orientation on a survey instrument for a national study

Palliative care needs in patients hospitalized with heart failure (PCHF) study: rationale and design

Abstract Aims The primary aim of this study is to provide data to inform the design of a randomized controlled clinical trial (RCT) of a palliative care (PC) intervention in heart failure (HF). We will identify an appropriate study population with a high prevalence of PC needs defined using quantifiable measures. We will also identify which components a specific and targeted PC intervention in HF should include and attempt to define the most relevant trial outcomes. Methods An unselected, prospective, near-consecutive, cohort of patients admitted to hospital with acute decompensated HF will be enrolled over a 2-year period. All potential participants will be screened using B-type natriuretic peptide and echocardiography, and all those enrolled will be extensively characterized in terms of their HF status, comorbidity, and PC needs. Quantitative assessment of PC needs will include evaluation of general and disease-specific quality of life, mood, symptom burden, caregiver burden, and end of life care. Inpatient assessments will be performed and after discharge outpatient assessments will be carried out every 4 months for up to 2.5 years. Participants will be followed up for a minimum of 1 year for hospital admissions, and place and cause of death. Methods for identifying patients with HF with PC needs will be evaluated, and estimates of healthcare utilisation performed. Conclusion By assessing the prevalence of these needs, describing how these needs change over time, and evaluating how best PC needs can be identified, we will provide the foundation for designing an RCT of a PC intervention in HF

Using research feedback loops to implement a disability case study with Aboriginal and Torres Strait Islander communities and service providers in regional and remote Australia

While there is a well-developed body of literature in the health field that describes processes to implement research, there is a dearth of similar literature in the disability field of research involving complex conditions. Moreover, the development of meaningful and sustainable knowledge translation is now a standard component of the research process. Knowledge users, including community members, service providers, and policy makers now call for evidence-led meaningful activities to occur rapidly. In response, this article presents a case study that explores the needs and priorities of Aboriginal and Torres Strait Islander women in Australia who have experienced a traumatic brain injury due to family violence. Drawing on the work of Indigenous disability scholars such as Gilroy, Avery and others, this article describes the practical and conceptual methods used to transform research to respond to the realities of community concerns and priorities, cultural considerations and complex safety factors. This article offers a unique perspective on how to increase research relevance to knowledge users and enhance the quality of data collection while also overcoming prolonged delays of knowledge translation that can result from the research-production process