Accountable Care in the Safety Net: A Case Study of the Cambridge Health Alliance

Following passage of health care reform in Massachusetts, the Cambridge Health Alliance (CHA), a public safety-net health system, began to establish an accountable care organization in an effort to continue its mission and remain financially solvent. In examining how CHA undertook its delivery system transformation, this case study explores the organization's four major strategies: establishing patient-centered medical homes, entering alternative payment arrangements with managed care organizations, launching complex care management, and establishing a partnership with a tertiary care institution. Workforce education and culture change were also core principles. Within two years, CHA had already received National Committee for Quality Assurance patient-centered medical home recognition for six of its primary care sites, and quality metrics demonstrate improvements in these sites compared with others. Moreover, utilization in one managed care organization is trending downward. Challenges persist, however, due in part to fiscal pressures created by state health care reform

Exploring the Impact of Language Services on Utilization and Clinical Outcomes for Diabetics

Background: Significant health disparities exist between limited English proficient and English-proficient patients. Little is known about the impact of language services on chronic disease outcomes such as for diabetes. Methods/Principal Findings: To determine whether the amount and type of language services received during primary care visits had an impact on diabetes-related outcomes (hospitalization, emergency room utilization, glycemic control) in limited English proficient patients, a retrospective cohort design was utilized. Hospital and medical record data was examined for 1425 limited English proficient patients in the Cambridge Health Alliance diabetes registry. We categorized patients receiving usual care into 7 groups based on the amount and combination of language services (language concordant providers, formal interpretation and nothing) received at primary care visits during a 9 month period. Bivariate analyses and multiple logistic regression were used to determine relationships between language service categories and outcomes in the subsequent 6 months. Thirty-one percent of patients (445) had no documentation of interpreter use or seeing a language concordant provider in any visits. Patients who received 100% of their primary care visits with language concordant providers were least likely to have diabetes-related emergency department visits compared to other groups (p<0001) in the following 6 months. Patients with higher numbers of co-morbidities were more likely to receive formal interpretation. Conclusions/Significance: Language concordant providers may help reduce health care utilization for limited English proficient patients with diabetes. However, given the lack of such providers in sufficient numbers to meet patients' communication needs, strategies are needed to both increase their numbers and ensure that the highest risk patients receive the most appropriate language services. In addition, systems serving diverse populations must clarify why some limited English proficient patients do not receive language services at some or all of their visits and whether this has an impact on quality of care

Intermediate to felsic middle crust in the accreted Talkeetna arc, the Alaska Peninsula and Kodiak Island, Alaska : an analogue for low-velocity middle crust in modern arcs

Author Posting. © American Geophysical Union, 2010. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Tectonics 29 (2010): TC3001, doi:10.1029/2009TC002541.Seismic profiles of several modern arcs have identified thick, low-velocity midcrustal layers (Vp = 6.0–6.5 km/s) that are interpreted to represent intermediate to felsic plutonic crust. The presence of this silicic crust is surprising given the mafic composition of most primitive mantle melts and could have important implications for the chemical evolution and bulk composition of arcs. However, direct studies of the middle crust are limited by the restricted plutonic exposures in modern arcs. The accreted Talkeetna arc, south central Alaska, exposes a faulted crustal section from residual subarc mantle to subaerial volcanic rocks of a Jurassic intraoceanic arc and is an ideal place to study the intrusive middle crust. Previous research on the arc, which has provided insight into a range of arc processes, has principally focused on western exposures of the arc in the Chugach Mountains. We present new U-Pb zircon dates, radiogenic isotope data, and whole-rock geochemical analyses that provide the first high-precision data on large intermediate to felsic plutonic exposures on Kodiak Island and the Alaska Peninsula. A single chemical abrasion–thermal ionization mass spectrometry analysis from the Afognak pluton yielded an age of 212.87 ± 0.19 Ma, indicating that the plutonic exposures on Kodiak Island represent the earliest preserved record of Talkeetna arc magmatism. Nine new dates from the extensive Jurassic batholith on the Alaska Peninsula range from 183.5 to 164.1 Ma and require a northward shift in the Talkeetna arc magmatic axis following initial emplacement of the Kodiak plutons, paralleling the development of arc magmatism in the Chugach and Talkeetna mountains. Radiogenic isotope data from the Alaska Peninsula and the Kodiak archipelago range from $\varepsilon$Nd(t) = 5.2 to 9.0 and 87Sr/86Srint = 0.703515 to 0.703947 and are similar to age-corrected data from modern intraoceanic arcs, suggesting that the evolved Alaska Peninsula plutons formed by extensive differentiation of arc basalts with little or no involvement of preexisting crustal material. The whole-rock geochemical data and calculated seismic velocities suggest that the Alaska Peninsula represents an analogue for the low-velocity middle crust observed in modern arcs. The continuous temporal record and extensive exposure of intermediate to felsic plutonic rocks in the Talkeetna arc indicate that evolved magmas are generated by repetitive or steady state processes and play a fundamental role in the growth and evolution of intraoceanic arcs

Effect of Pediatric Behavioral Health Screening and Colocated Services on Ambulatory and Inpatient Utilization

Objective The study sought to determine the impact of a pediatric behavioral health (BH) screening and co-location model on BH care utilization Methods In 2003, Cambridge Health Alliance, a Massachusetts public health system introduced BH screening and co-location of social workers within its pediatric practices in a sequential manner. An interrupted time series study of the change in trends of ambulatory, emergency and inpatient BH utilization in the 30 months following model implementation compared to the 18 months prior was conducted to determine the impact of this model on BH care utilization, Utilization data on 11,223 children ≥4 years 9 months to < 18 years 3 months seen from 2003 to 2008, contributed to the study. Results In the 30 months following implementation of pediatric BH screening and co-location there was a 20.4% cumulative increase in specialty BH visit rates (trend = 0.013% per month; p=0.049), and 67.7% cumulative increase in BH primary care visit rates (trend = 0.019% per month; p=0.002) compared to the expected rate predicted by the 18 month pre- intervention trend. In addition, BH emergency department visit rates increased 245% compared to the expected rate (trend = 0.01% per month; p<.001). Conclusions Following the implementation of a BH screening/co-location model, more children received BH treatment. Contrary to expectations, BH emergency department visits also increased. Further study is needed to determine if this is an effect of how care was organized for children newly engaged in BH care or a reflection of secular trends in BH utilization or both

Osmium isotope systematics of the Proterozoic and Phanerozoic ophiolitic chromitites : in situ ion probe analysis of primary Os-rich PGM

Author Posting. © Elsevier B.V., 2006. This is the author's version of the work. It is posted here by permission of Elsevier B.V. for personal use, not for redistribution. The definitive version was published in Earth and Planetary Science Letters 245 (2006): 777-791, doi:10.1016/j.epsl.2006.03.021.In-situ 187Os/188Os ratios are determined on Os-rich platinum-group minerals in podiform chromitites both in the Proterozoic ophiolite, Eastern Desert, Egypt, and in the Phanerozoic Oman ophiolite. Because they have very low Re/Os, these primary minerals reflect the initial 187Os/188Os ratios of their parental magmas. The platinum-group minerals (PGM) in the central Eastern Desert chromitites exhibit sub-chondritic to chondritic 187Os/188Os ratios, 0.1226 on average, which is lower than the primitive upper mantle evolution trend of a comparable age. Those of the southern Eastern Desert chromitites have more radiogenic Os, with supra-chondritic 187Os/188Os ratio of about 0.1293 on average, which could be due to crustal contamination. The three chromitite types in the northern part of the Oman ophiolite are almost indistinguishable in terms of their 187Os/188Os ratios; they have overlapping values ranging from sub-chondritic to supra-chondritic ratios. The PGE-rich, mantle chromitite samples have a wide range of 187Os/188Os ratio from 0.1230 up to 0.1376, with an average of 0.1299. The values of the PGE-poor mantle chromitites overlap in their 187Os/188Os ratios with PGE-rich chromites, but are less variable and have a significantly higher average ratio. The Moho transition zone (MTZ) chromitites are highly variable in the 187Os/188Os ratio, ranging from 0.1208 up to 0.1459. The wide range of 187Os/188Os ratios, from 0.1192 to 0.1459, in platinum-group minerals in Egyptian and Oman ophiolites can be attributed to the diversity of origin of their podiform chromitites. The Os-isotope data combined with spinel chemistry indicate that the way involved in podiform chromitite formation was not substantially different between the Proterozoic ophiolite of Egypt and the Phanerozoic ophiolite in northern Oman. The Os-isotope compositions of the mantle chromitites in the Proterozoic ophiolite of Egypt clearly suggest crustal contamination. The heterogeneity of 187Os/188Os ratios combined with the spinel chemistry and high PGE contents of the PGE-rich chromitite in the Oman ophiolite may give reliable evidence for high degree partial melting at a supra-subduction zone setting. Crustal contamination from the subducted slab, and assimilation of previously altered, lower crustal gabbro, may have contributed to the high Cr# spinel and radiogenic Os characteristics in chromitite formed in the mantle section and along the Moho transition zone, respectively.Kelemen and Hanghøj were supported in this project by US National Science Foundation grants OCE-9819666 and OCE-0118572

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe