The transformation of community hospitals through the transition to value-based care: Lessons from Massachusetts

Enabling community hospitals to provide efficient and effective care and maintain competition on par with their academic medical center (AMC) counterparts remain challenges for most states. Advancing accountable care readiness adds to the complexity of these challenges. Community hospitals experience narrower operating margins and more limited access to large populations than their AMC counterparts, making the shift to value-based care difficult. Massachusetts has taken legislative action to ensure a statewide focus on reducing healthcare costs, which includes a nearly $120-million grant program supporting community hospital and system transformation toward a value-based environment. The Massachusetts Health Policy Commission’s Community Hospital Acceleration, Revitalization and Transformation (CHART) investment program is the state’s largest effort to date aimed at readying community hospitals for value-based care. In doing so, Massachusetts has created the largest state-driven, all-payer (payer-blind) readmission reduction initiative in the country. n this paper, we examine the design and evolution of CHART Phases 1 and 2 and offer insights for other states contemplating innovative approaches to bolstering community hospital participation in value-based care models

Effect of Omega-3 Fatty Acids on Lipoprotein Profile and Particle Size in Hispanic Women

The effect of increased Ω3 fatty acids on lipoprotein sub-fractions has not been well studied in Hispanic women, a group with a high prevalence of dyslipidemia and metabolic syndrome. The purpose of this randomized, placebo-controlled trial was to examine the effect of a 90-day (90D) combined EPA+DHA supplementation on lipoprotein profiles of Hispanic women. Twenty-seven non-diabetic women were randomly assigned to the Ω3 group (n=17, 1.9 g/day EPA+DHA) or the placebo group (n=10, 2 g/day oleic acid). At baseline (0D) and 90D a fasting blood sample was drawn for determination of lipoprotein profile and lipoprotein particle sub-fractions. For the Ω3 group, total cholesterol increased 6.5%, triglycerides were reduced 14.8%, LDL concentration increased 5.6%, and total LDL particle size concentration increased 8.2% (P \u3c 0.05). Large LDL particle size concentration increased 16% from 0D to 90D, this change was not significant (P = 0.051). At 90D, total cholesterol, LDLs, and LDL particle concentration were higher in the Ω3 group compared to placebo (P \u3c 0.05). Omega-3 supplementation resulted in reduced plasma TGs and an increase in large LDL particle size concentration, yet had no effect on HDL particle size or concentration. Further research is necessary to examine the effects of increased Ω3 fatty acid intake in Hispanic women on dyslipidemia and related co-morbidities

Cardiometabolic Plasticity in Response to a Short-Term Diet and Exercise Intervention in Young Hispanic and NonHispanic White Adults

BACKGROUND: Young adult Mexican Americans (MA) exhibit lower insulin sensitivity (Si) than nonHispanic whites (NHW), even when controlling for fitness and adiposity. It is unclear if MA are as responsive to the same lifestyle intervention as NHW. OBJECTIVE: We developed a model to examine cardiometabolic plasticity (i.e., changes in Si and plasma lipids) in MA compared to NHW adults in response to a diet-exercise intervention. DESIGN: Sedentary subjects (20 NHW: 11F, 9M, 23.0 y, 25.5 kg/m(2); 17 MA: 13F, 4M, 22.7 y, 25.4 kg/m(2)) consumed their habitual diets and remained sedentary for 7 days, after which fasting blood samples were obtained, and a 3-h intravenous glucose tolerance test (IVGTT) was performed with the insulin area under the curve (IAUC) used to estimate Si. Subjects then completed a 7-day diet/exercise intervention (diet: low saturated fat, low added sugar, high fiber; exercise: cycling, six total sessions lasting 40-45 min/session at 65% VO(2) max). Pre-intervention tests were repeated. RESULTS: Pre intervention IAUC was 28% higher (p<0.05) in MA (IAUC pre  =  2298 µU*180 min/mL) than in NHW (IAUC = 1795 µU*180 min/mL). Following the intervention, there was a significant reduction in IAUC in MA (29%) and NHW (32%), however, the IAUC remained higher (p<0.05) for MA (post  = 1635 µU*180 min/mL) than for NHW (post = 1211 µU*180 min/mL). Pre test plasma lipids were not different in MA compared to NHW. Plasma cholesterol and TG concentrations significantly improved in both groups, but concentrations of low density lipoprotein-cholesterol and small dense LDL particles significantly improved only in the NHW. CONCLUSION: With a short-term diet-exercise intervention, the magnitude of improvements in Si and serum cholesterol and TG in Hispanics are similar to those in NHW. However, because at the outset MA were less insulin sensitive compared to NHW, within the short timeframe studied the ethnic gap in insulin sensitivity remained

Does prior acute exercise affect postexercise substrate oxidation in response to a high carbohydrate meal?

<p>Abstract</p> <p>Background</p> <p>Consumption of a mixed meal increases postprandial carbohydrate utilization and decreases fat oxidation. On the other hand, acute endurance exercise increases fat oxidation and decreases carbohydrate utilization during the post-exercise recovery period. It is possible that the resulting post-exercise increase in circulating nonesterified fatty acids could attenuate the ability of ingested carbohydrate to inhibit lipid oxidation. The purpose of this study was to determine whether prior exercise attenuates the usual meal-induced decline in lipid oxidation.</p> <p>Methods</p> <p>Six healthy, physically active young subjects (x age = 26.3 years, 4 males, 2 females) completed three treatments in random order after a ~10 h fast: (a) Exercise/Carbohydrate (Ex/CHO) – subjects completed a bout of exercise at 70% VO_2peak(targeted net energy cost of 400 kcals), followed by consumption of a carbohydrate-rich meal; (b) Exercise/Placebo (Ex/Placebo) – subjects completed an identical bout of exercise followed by consumption of a placebo; and (c) No Exercise/Carbohydrate (NoEx/CHO) – subjects sat quietly rather than exercising and then consumed the carbohydrate-rich meal. Blood samples were obtained before and during the postprandial period to determine plasma glucose, insulin, and non-esterified fatty acids (NEFA). Respiratory gas exchange measures were used to estimate rates of fat and carbohydrate oxidation.</p> <p>Results</p> <p>Plasma NEFA were approximately two-fold higher immediately following the two exercise conditions compared to the no-exercise condition, while meal consumption significantly increased insulin and glucose in both Ex/CHO and NoEx/CHO. NEFA concentrations fell rapidly during the 2-h postprandial period, but remained higher compared to the NoEx/CHO treatment. Carbohydrate oxidation increased rapidly and fat oxidation decreased in response to the meal, with no differences in the rates of carbohydrate and fat oxidation during recovery between the Ex/CHO and NoEx/CHO conditions.</p> <p>Conclusion</p> <p>The plasma NEFA concentration is increased during the post exercise period, which is associated with elevated fat oxidation when no meal is consumed. However, when a mixed meal is consumed immediately following exercise, the initially elevated plasma NEFA concentration decreases rapidly, and postexercise fat oxidation during this 2-h postexercise, postprandial period is no higher than that of the 2-h postprandial period without prior exercise.</p

Cohesin biology meets the loop extrusion model

Extensive research has revealed that cohesin acts as a topological device, trapping chromosomal DNA within a large tripartite ring. In so doing, cohesin contributes to the formation of compact and organized genomes. How exactly the cohesin subunits interact, how it opens, closes, and translocates on chromatin, and how it actually tethers DNA strands together are still being elucidated. A comprehensive understanding of these questions will shed light on how cohesin performs its many functions, including its recently proposed role as a chromatid loop extruder. Here, we discuss this possibility in light of our understanding of the molecular properties of cohesin complexes