Addressing Bias and Racism Against Asian American, Native Hawaiian, and Pacific Islander Individuals: A Call to Action to Advance Health Equity and Leadership

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Early winners and losers in dialysis center pay-for-performance

Abstract Background We examined the association of dialysis facility characteristics with payment reductions and change in clinical performance measures during the first year of the United States Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease Quality Incentive Plan (ESRD QIP) to determine its potential impact on quality and disparities in dialysis care. Methods We linked the 2012 ESRD QIP Facility Performance File to the 2007–2011 American Community Survey by zip code and dichotomized the QIP total performance scores—derived from percent of patients with urea reduction rate > 65, hemoglobin  12 g/dL—as ‘any’ versus ‘no’ payment reduction. We characterized associations between payment reduction and dialysis facility characteristics and neighborhood demographics, and examined changes in facility outcomes between 2007 and 2010. Results In multivariable analysis, facilities with any payment reduction were more likely to have longer operation (OR 1.03 per year), a medium or large number of stations (OR 1.31 and OR 1.42, respectively), and a larger proportion of African Americans (OR 1.25, highest versus lowest quartile), all p < 0.05. Most improvement in clinical performance was due to reduced overtreatment of anemia, a decline in the percentage of patients with hemoglobin ≥ 12 g/dL; for-profits and facilities in African American neighborhoods had the greatest reduction. Conclusions In the first year of CMS pay-for-performance, most clinical improvement was due to reduced overtreatment of anemia. Facilities in African American neighborhoods were more likely to receive a payment reduction, despite their large decline in anemia overtreatment.https://deepblue.lib.umich.edu/bitstream/2027.42/139722/1/12913_2017_Article_2764.pd

Enhancing evidence-based diabetes and chronic disease control among local health departments: A multi-phase dissemination study with a stepped-wedge cluster randomized trial component

Examples of Intervention Dissemination Strategies and Description. (DOCX 22 kb

Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making

<p>Abstract</p> <p>Background</p> <p>Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD.</p> <p>Methods</p> <p>We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision.</p> <p>Results</p> <p>More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24).</p> <p>Conclusions</p> <p>In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.</p

Causality in relativistic many body theory

The stability of the nuclear matter system with respect to density fluctuations is examined exploring in detail the pole structure of the electro-nuclear response functions. Making extensive use of the method of dispersion integrals we calculate the full polarization propagator not only for real energies in the spacelike and timelike regime but also in the whole complex energy plane. The latter proved to be necessary in order to identify unphysical causality violating poles which are the consequence of a neglection of vacuum polarization. On the contrary it is shown that Dirac sea effects stabilize the nuclear matter system shifting the unphysical pole from the upper energy plane back to the real axis. The exchange of strength between these real timelike collective excitations and the spacelike energy regime is shown to lead to a reduction of the quasielastic peak as it is seen in electron scattering experiments. Neglecting vacuum polarization one also obtains a reduction of the quasielastic peak but in this case the strength is partly shifted to the causality violating pole mentioned above which consequently cannot be considered as a physical reliable result. Our investigation of the response function in the energy region above the threshold of nucleon anti-nucleon production leads to another remarkable result. Treating the nucleons as point-like Dirac particles we show that for any isospin independent NN-interaction RPA-correlations provide a reduction of the production amplitude for $p\bar p$-pairs by a factor 2.Comment: 19 pages Latex including 12 postscript figure

Improving the Effectiveness of Health Care Innovation Implementation: Middle Managers as Change Agents

The rate of successful health care innovation implementation is dismal. Middle managers have a potentially important yet poorly understood role in health care innovation implementation. This study used self-administered surveys and interviews of middle managers in health centers that implemented an innovation to reduce health disparities to address the questions: Does middle managers’ commitment to health care innovation implementation influence implementation effectiveness? If so, in what ways does their commitment influence implementation effectiveness? Although quantitative survey data analysis results suggest a weak relationship, qualitative interview data analysis results indicate that middle managers’ commitment influences implementation effectiveness when middle managers are proactive. Scholars should account for middle managers’ influence in implementation research, and health care executives may promote implementation effectiveness by hiring proactive middle managers and creating climates in which proactivity is rewarded, supported, and expected

A Close Binary Star Resolved from Occultation by 87 Sylvia

The star BD+29 1748 was resolved to be a close binary from its occultation by the asteroid 87 Sylvia on 2006 December 18 UT. Four telescopes were used to observe this event at two sites separated by some 80 km apart. Two flux drops were observed at one site, whereas only one flux drop was detected at the other. From the long-term variation of Sylvia, we inferred the probable shape of the shadow during the occultation, and this in turn constrains the binary parameters: the two components of BD+29 1748 have a projected separation of 0.097" to 0.110" on the sky with a position angle 104 deg to 107 deg. The asteroid was clearly resolved with a size scale ranging from 130 to 290 km, as projected onto the occultation direction. No occultation was detected for either of the two known moonlets of 87 Sylvia.Comment: 12 pages, 4 figures, 2 tables; submitted to the PAS