The Impact of Insurance and a Usual Source of Care on Emergency Department Use in the United States

Background. Finding a usual source of care (USC) is difficult for certain populations. This analysis determines how insurance type and having a USC affect the settings in which patients seek care. Methods. In this cross-sectional study of the 2000–2011 Medical Expenditure Panel Surveys, we assessed the percentage of low-income persons with half or more of their ambulatory visits to the emergency department (ED). Respondents were stratified based on insurance type and presence of a USC. Results. In 2011, among Medicaid enrollees without USCs, 21.6% had half or more of their ambulatory visits to EDs compared to 8.1% for those with USCs. Among the uninsured without USCs, 24.1% went to an ED for half or more of their ambulatory visits compared to 8.8% for those with USCs in 2011. Among the privately insured without USCs, 7.8% went to an ED for half or more of their ambulatory visits compared to 5.0% for those with USCs in 2011. These differences remained in multivariate analyses. Conclusions. Those who lack USCs, particularly the uninsured and Medicaid enrollees, are more likely to rely on EDs

Core Principles to Improve Primary Care Quality Management

Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine. Increasingly, its contribution to achieving the Quadruple Aim is under close examination, especially in the domain of primary care services, where the burden of measurement is heaviest. This article assesses the state of quality management in primary care in the United States, particularly the 2015 Medicare Access and Children’s Health Insurance Program Reauthorization Act, in comparative perspective, drawing lessons from the Quality and Outcomes Framework in the United Kingdom. The health care delivery function specific to primary care is pivotal to crossing the quality chasm, yet prior efforts to improve the quality of this function have failed more often than succeeded. These failures are the result of quality programs unguided by core principles of primary care. Quality management in primary care requires a more disciplined approach, adherent to 4 foundational principles: optimizing holistic patient and population health; harnessing the Quadruple Aim as a dynamic whole; applying measurements as tools for quality, not outcomes of quality; and prioritizing therapeutic relationships. These principles serve as the foundation for a bridge to high-functioning primary care that will lead American health care closer to the Quadruple Aim

Developing a Health Care Workforce That Supports Team-Based Care Models That Integrate Health and Social Services

Across the country, health care professionals are joining forces to improve the health care of populations with complex social, financial, and behavioral health needs. One promising approach relies on community-based integrated health teams (CIHTs), or interprofessional teams that integrate a broad range of medical, behavioral health, and social services, offer intensive case management, and link patients to available community resources. Yet whether CIHTs fulfill their potential depends in part on policymakers enacting policies that support CIHTs delivering comprehensive, high-value care to their patients. Drawing on the insights of CIHT professionals shared with the authors, this Article highlights several factors that contribute to CIHTs’ success, namely utilizing community health workers (CHWs) to provide patients with high-touch care, including behavioral health experts on the care team, and increasing coordination between CIHTs and patients’ primary care providers. The Article then calls for federal and state policies that would promote expansion of the CHW and behavioral health workforce, provide more flexible and sustainable financing to CIHTs, and support primary care providers acquiring the financial resources, data capabilities, and personnel needed to either embedding CIHTs within their practices or coordinate with outside CIHTs

Honey Bee PTEN – Description, Developmental Knockdown, and Tissue-Specific Expression of Splice-Variants Correlated with Alternative Social Phenotypes

Phosphatase and TENsin (PTEN) homolog is a negative regulator that takes part in IIS (insulin/insulin-like signaling) and Egfr (epidermal growth factor receptor) activation in Drosophila melanogaster. IIS and Egfr signaling events are also involved in the developmental process of queen and worker differentiation in honey bees (Apis mellifera). Here, we characterized the bee PTEN gene homologue for the first time and begin to explore its potential function during bee development and adult life.Honey bee PTEN is alternatively spliced, resulting in three splice variants. Next, we show that the expression of PTEN can be down-regulated by RNA interference (RNAi) in the larval stage, when female caste fate is determined. Relative to controls, we observed that RNAi efficacy is dependent on the amount of PTEN dsRNA that is delivered to larvae. For larvae fed queen or worker diets containing a high amount of PTEN dsRNA, PTEN knockdown was significant at a whole-body level but lethal. A lower dosage did not result in a significant gene down-regulation. Finally, we compared same-aged adult workers with different behavior: nursing vs. foraging. We show that between nurses and foragers, PTEN isoforms were differentially expressed within brain, ovary and fat body tissues. All isoforms were expressed at higher levels in the brain and ovaries of the foragers. In fat body, isoform B was expressed at higher level in the nurse bees.Our results suggest that PTEN plays a central role during growth and development in queen- and worker-destined honey bees. In adult workers, moreover, tissue-specific patterns of PTEN isoform expression are correlated with differences in complex division of labor between same-aged individuals. Therefore, we propose that knowledge on the roles of IIS and Egfr activity in developmental and behavioral control may increase through studies of how PTEN functions can impact bee social phenotypes

Honey Bee PTEN – Description, Developmental Knockdown, and Tissue-Specific Expression of Splice-Variants Correlated with Alternative Social Phenotypes

Phosphatase and TENsin (PTEN) homolog is a negative regulator that takes part in IIS (insulin/insulin-like signaling) and Egfr (epidermal growth factor receptor) activation in Drosophila melanogaster. IIS and Egfr signaling events are also involved in the developmental process of queen and worker differentiation in honey bees (Apis mellifera). Here, we characterized the bee PTEN gene homologue for the first time and begin to explore its potential function during bee development and adult life.Honey bee PTEN is alternatively spliced, resulting in three splice variants. Next, we show that the expression of PTEN can be down-regulated by RNA interference (RNAi) in the larval stage, when female caste fate is determined. Relative to controls, we observed that RNAi efficacy is dependent on the amount of PTEN dsRNA that is delivered to larvae. For larvae fed queen or worker diets containing a high amount of PTEN dsRNA, PTEN knockdown was significant at a whole-body level but lethal. A lower dosage did not result in a significant gene down-regulation. Finally, we compared same-aged adult workers with different behavior: nursing vs. foraging. We show that between nurses and foragers, PTEN isoforms were differentially expressed within brain, ovary and fat body tissues. All isoforms were expressed at higher levels in the brain and ovaries of the foragers. In fat body, isoform B was expressed at higher level in the nurse bees.Our results suggest that PTEN plays a central role during growth and development in queen- and worker-destined honey bees. In adult workers, moreover, tissue-specific patterns of PTEN isoform expression are correlated with differences in complex division of labor between same-aged individuals. Therefore, we propose that knowledge on the roles of IIS and Egfr activity in developmental and behavioral control may increase through studies of how PTEN functions can impact bee social phenotypes

Assessing COVID-19 risk, vulnerability and infection prevalence in communities.

BackgroundThe spread of coronavirus in the United States with nearly five and half million confirmed cases and over 170,000 deaths has strained public health and health care systems. While many have focused on clinical outcomes, less attention has been paid to vulnerability and risk of infection. In this study, we developed a planning tool that examines factors that affect vulnerability to COVID-19.MethodsAcross 46 variables, we defined five broad categories: 1) access to medical services, 2) underlying health conditions, 3) environmental exposures, 4) vulnerability to natural disasters, and 5) sociodemographic, behavioral, and lifestyle factors. The developed tool was validated by comparing the estimated overall vulnerability with the real-time reported normalized confirmed cases of COVID-19.AnalysisA principal component analysis was undertaken to reduce the dimensions. In order to identify vulnerable census tracts, we conducted rank-based exceedance and K-means cluster analyses.ResultsAll of the 5 vulnerability categories, as well as the overall vulnerability, showed significant (P-values ConclusionPolicymakers can use this planning tool to identify neighborhoods at high risk for becoming hot spots; efficiently match community resources with needs, and ensure that the most vulnerable have access to equipment, personnel, and medical interventions

Adults with Housing Insecurity Have Worse Access to Primary and Preventive Care.

ObjectiveHousing insecurity has been linked to high-risk behaviors and chronic disease, although less is known about the pathways leading to poor health. We sought to determine whether housing insecurity is associated with access to preventive and primary care.MethodsWe conducted weighted univariate, bivariate, and multivariate analyses by using 2011 to 2015 Behavioral Risk factor Surveillance Survey data (N = 228,131 adults). The independent variable was housing insecurity derived from the question on worry about paying rent or mortgage. The outcome measures were health services utilization (no usual source of care, no routine checkup in the past 1 year, and delayed medical care due to cost), self-rated health (number of days reported physical, mental health not good, and poor overall health), and number of chronic diseases (0, 1, 2 or more). The covariates included age, sex, race/ethnicity, income, level of education, marital status, and number of children in the family. We also adjusted for state fixed effects and survey year. We performed χ2 tests and binary logistic regressions on categorical variables and ran t tests and estimated linear regression models on continuous variables. Multinomial logistic regressions were estimated for the number of chronic diseases.ResultsOf the 228,131 adults in the study sample, 28,704 adults reported housing insecurity. We found that those with housing insecurity were more likely to forgo routine check-ups and lack usual sources of care. Low-income individuals, minorities, the unmarried, and middle-aged adults were more likely to report housing insecurity.ConclusionHousing insecurity is associated with worse access to preventive and primary care. Interventions to enhance access for these patients should be developed and studied