The Limits of Accountability: A Prospective Policy Analysis of Accountable Care Organizations

In a short period of time policymakers have propelled accountability from theory to practice in the form of the Accountable Care Organization (ACO). A mixed model of delivery and payment reform, the ACO is theorized to curb Medicare spending by incentivizing groups of physicians and other caregivers to provide coordinated and high quality care across diverse health care settings. Although ACOs are unlikely to cure all that ails America’s health system, results from ACO-like experiments such as the Physician Group Practice Demonstration (PGPD) have fueled policymakers’ hopes that ACOs will produce significant cost savings. Although the definitive structure of ACOs has yet to be resolved, a provisional rule recently proposed by the Centers for Medicare and Medicaid Services (CMS) offers a glimpse of their likely form. The ACO model is appealing in theory, but the current proposal for implementation suggests that ACOs may fail to yield significant cost savings to Medicare. If implemented as currently elaborated, ACOs may be limited by weak financial incentives and low participation among physicians. Of particular concern is the lack of meaningful payment reform. The current proposal suggests ACOs will do little to disrupt the prevailing incentive structure embedded in the Medicare Fee Schedule (MFS). The purpose of this paper is to explore the limitations of CMS’ current proposal and how these limitations may constrain projected cost savings. This paper will also propose alternatives that may better promote the ideals of ACOs while ensuring that significant cost savings are achieved.Master of Public Healt

Coarse Particulate Matter (PM(2.5–10)) Affects Heart Rate Variability, Blood Lipids, and Circulating Eosinophils in Adults with Asthma

INTRODUCTION: We investigated whether markers of airway and systemic inflammation, as well as heart rate variability (HRV) in asthmatics, change in response to fluctuations in ambient particulate matter (PM) in the coarse [PM with aerodynamic diameter 2.5–10 μm (PM(2.5–10))] and fine (PM(2.5)) size range. METHODS: Twelve adult asthmatics, living within a 30-mile radius of an atmospheric monitoring site in Chapel Hill, North Carolina, were followed over a 12-week period. Daily PM(2.5–10) and PM(2.5) concentrations were measured separately for each 24-hr period. Each subject had nine clinic visits, at which spirometric measures and peripheral blood samples for analysis of lipids, inflammatory cells, and coagulation-associated proteins were obtained. We also assessed HRV [SDNN24HR (standard deviation of all normal-to-normal intervals in a 24-hr recording), ASDNN5 (mean of the standard deviation in all 5-min segments of a 24-hr recording)] with four consecutive 24-hr ambulatory electrocardiogram measurements. Linear mixed models with a spatial covariance matrix structure and a 1-day lag were used to assess potential associations between PM levels and cardiopulmonary end points. RESULTS: For a 1-μg/m(3) increase in coarse PM, SDNN24HR, and ASDNN5 decreased 3.36% (p = 0.02), and 0.77%, (p = 0.05) respectively. With a 1-μg/m(3) increase in coarse PM, circulating eosinophils increased 0.16% (p = 0.01), triglycerides increased 4.8% (p = 0.02), and very low-density lipoprotein increased 1.15% (p = 0.01). No significant associations were found with fine PM, and none with lung function. CONCLUSION: These data suggest that small temporal increases in ambient coarse PM are sufficient to affect important cardiopulmonary and lipid parameters in adults with asthma. Coarse PM may have underappreciated health effects in susceptible populations

13kW Advanced Electric Propulsion Flight System Development and Qualification

The next phase of robotic and human deep space exploration missions is enhanced by high performance, high power solar electric propulsion systems for large-scale science missions and cargo transportation. Aerojet Rocketdynes Advanced Electric Propulsion System (AEPS) program is completing development, qualification and delivery of five flight 13.3kW EP systems to NASA. The flight AEPS includes a magnetically-shielded, long-life Hall thruster, power processing unit (PPU), xenon flow controller (XFC), and intrasystem harnesses. The Hall thruster, originally developed and demonstrated by NASAs Glenn Research Center and the Jet Propulsion Laboratory, operates at input powers up to 12.5kW while providing a specific impulse over 2600s at an input voltage of 600V. The power processor is designed to accommodate an input voltage range of 95 to 140V, consistent with operation beyond the orbit of Mars. The integrated system is continuously throttleable between 3 and 13.3kW. The program has completed the system requirement review; the system, thruster, PPU and XFC preliminary design reviews; development of engineering models, and initial system integration testing. This paper will present the high power AEPS capabilities, overall program and design status and the latest test results for the 13.3kW flight system development and qualification program

Age of Pseudomonas aeruginosa acquisition and subsequent severity of cystic fibrosis lung disease

Rationale: Pseudomonas aeruginosa (Pa) is associated with poor pulmonary outcomes in cystic fibrosis (CF), but the association between age of Pa infection and severity of subsequent lung disease has not been thoroughly investigated. Objective: Our goal was to determine the association between age of Pa acquisition and subsequent severity of CF lung disease. Methods: Case–control study using CF Foundation Registry data of 629 ΔF508 homozygotes with severe and mild lung disease (FEV1 in the lowest and highest quartile of birth cohort, respectively). Multivariate logistic regression was performed to determine the association between age of Pa acquisition and lung disease severity. Results: Earlier age of Pa infection was strongly associated with increased odds of severe lung disease. For first and persistent Pa, adjusted odds ratios for severe lung disease were 6.5 (95% CI 3.1, 13.7; P < 0.0001) and 11.2 (5.4, 23.1; P < 0.0001), respectively, for subjects with infection before age 5 versus at ≥10 years; the association was stronger in females than males. Conclusions: Earlier Pa infection, particularly before 5 years of age, is strongly associated with severe CF lung disease later in life. This study is not designed to determine causality; Pa infection may be causing lung injury, or may be a marker of ongoing inflammation and lung damage in young children with CF

Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome : Insights from the LUNG SAFE study

Publisher Copyright: © 2020 The Author(s). Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). Conclusions: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073publishersversionPeer reviewe

Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database

Background: Diabetes mellitus is a common co-existing disease in the critically ill. Diabetes mellitus may reduce the risk of acute respiratory distress syndrome (ARDS), but data from previous studies are conflicting. The objective of this study was to evaluate associations between pre-existing diabetes mellitus and ARDS in critically ill patients with acute hypoxemic respiratory failure (AHRF). Methods: An ancillary analysis of a global, multi-centre prospective observational study (LUNG SAFE) was undertaken. LUNG SAFE evaluated all patients admitted to an intensive care unit (ICU) over a 4-week period, that required mechanical ventilation and met AHRF criteria. Patients who had their AHRF fully explained by cardiac failure were excluded. Important clinical characteristics were included in a stepwise selection approach (forward and backward selection combined with a significance level of 0.05) to identify a set of independent variables associated with having ARDS at any time, developing ARDS (defined as ARDS occurring after day 2 from meeting AHRF criteria) and with hospital mortality. Furthermore, propensity score analysis was undertaken to account for the differences in baseline characteristics between patients with and without diabetes mellitus, and the association between diabetes mellitus and outcomes of interest was assessed on matched samples. Results: Of the 4107 patients with AHRF included in this study, 3022 (73.6%) patients fulfilled ARDS criteria at admission or developed ARDS during their ICU stay. Diabetes mellitus was a pre-existing co-morbidity in 913 patients (22.2% of patients with AHRF). In multivariable analysis, there was no association between diabetes mellitus and having ARDS (OR 0.93 (0.78-1.11); p = 0.39), developing ARDS late (OR 0.79 (0.54-1.15); p = 0.22), or hospital mortality in patients with ARDS (1.15 (0.93-1.42); p = 0.19). In a matched sample of patients, there was no association between diabetes mellitus and outcomes of interest. Conclusions: In a large, global observational study of patients with AHRF, no association was found between diabetes mellitus and having ARDS, developing ARDS, or outcomes from ARDS. Trial registration: NCT02010073. Registered on 12 December 2013

Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries

Background: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. Methods: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Results: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. Conclusions: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013

TEXT COMPREHENSION OF VARIOUS VERSIONS OF THE BIBLE

This study evaluated the comprehensibility of six versions of the Bible: the King James Version (KJV), the Revised Standard Version (RSV), the New English Bible (NEB), Today\u27s English Version (TEV), the Living Bible (LB), and the New International Version (NIV). The subjects were 324 undergraduates from a Christian liberal arts college in the eastern United States. They were designated as either liberals or conservatives by a median split based on their scores on the Biblical Literalism Scale. Nine liberals and nine conservatives were then assigned at random to each biblical passage in each version. The experimental design included three independent variables: biblical version (KJV, RSV, NEB, TEV, LB, NIV); theological orthodoxy (liberal, conservative); and type of literature (narrative, poetry, proclamation). Two dependent variables, comprehensibility ratings (seven-point scale) and recall proportions (number of textual units recalled as a percentage of the total possible) were investigated. The 6 x 2 x 3 analysis of variance revealed a main effect for the Biblical versions both on the comprehensibility ratings and on the recall proportions. This verified that differences among the versions did exist. The nature of these differences was probed in four major areas. First, differences between the KJV and the five modern versions were explored. The KJV was judged to be less comprehensible than were the modern versions, and the modern versions facilitated better recall than did the KJV. Second, differences among the modern versions were probed. It was found that the LB and TEV were judged to more comprehensible than either the RSV or NEB. Third, differences for each type of literature were considered. For narrative literature, no difference among individual versions could be detected by either dependent variable. For poetic literature, it was found that the TEV and LB were judged by subjects to be more comprehensible than the KJV and that the NIV was recalled better than either the RSV or the KJV. On proclamation literature, the LB was judged to be more comprehensible than both the KJV and NEB. Fourth, no difference was found between liberals and conservatives in their comprehensibility ratings or in their ability to recall the various versions of the Bible