Eliminating waste in US health care: evaluating accountable care organizations as a model for quality sustainable care

Thesis (M.A.)--Boston UniversityIn 2011, the United States spent $2.7 trillion in health care expenditures, accounting for 17.9 percent of the Gross Domestic Product (GDP). Health care spending increased by 3.9 percent in 2011 and is expected to surpass 20 percent of GDP by 2020. An investigation of national trends in health spending conducted by the Institute of Medicine (IOM) estimates that approximately 30 percent of US health expenditures—that is, about$750 billion—is wasteful spending. Analysis of spending trends suggests waste in health care falls into one of six categories: (1) failures in care delivery; (2) failures in care coordination; (3) overtreatment; (4) administrative complexity; (5) pricing failures; (6) and fraud and abuse. A sustainable level of health spending would be one that grows at the same rate as the GDP; this would require cutting health care expenditures by an estimated $2.2 trillion by 2020. Distributing these cuts across the spectrum of wasteful spending by specifically targeting cost-containment efforts toward those areas of waste, it is possible—albeit challenging—to create a more solvent health care system. The Patient Protection and Affordable Care Act of 2010 (ACA), landmark legislation of the Obama administration, introduced extensive policy changes and addressed the unsustainable trajectory of Medicare with the debut of the Accountable Care Organization (ACO). The novel ACO design aims to bring hospitals and physician groups into partnerships with the common goal of providing quality, affordable care to a defined population of patients with the introduction of a Shared Savings Program and a triple aim of: (1) improving population health; (2) providing higher quality-care experiences; and (3) moderating per-capita health care cost increases. The ACO has the potential to address each of the six areas of waste specified by the Institute of Medicine, bringing health care expenditures down to sustainable levels, while also increasing the quality of care and the efficiency of US health care overall. The ACO model is promising, but poses its own challenges as a largely untested health system structure, and will require extensive efforts to refine and perfect the model in order to be a feasible answer to the US health care crisis

Road Map to the Revolution: A Practical Guide to Procedural Issues Before the Growth Management Hearings Boards

The adoption of the Washington Growth Management Act (GMA or the Act ) marked a major change in local government land use decision-making in the State of Washington. The Act\u27s requirement that local governments adopt a comprehensive land use plan (Plan) to guide development consistent with goals adopted by the state legislature and then implement that Plan with consistent regulations was a revolutionary step toward statewide land use planning. Much has been written about the GMA revolution. These writings primarily focus on the GMA\u27s procedural and substantive requirements for adoption of Plans and how these mandates have changed the face of land use planning in Washington State

Road Map to the Revolution: A Practical Guide to Procedural Issues Before the Growth Management Hearings Boards

The adoption of the Washington Growth Management Act (GMA or the Act ) marked a major change in local government land use decision-making in the State of Washington. The Act\u27s requirement that local governments adopt a comprehensive land use plan (Plan) to guide development consistent with goals adopted by the state legislature and then implement that Plan with consistent regulations was a revolutionary step toward statewide land use planning. Much has been written about the GMA revolution. These writings primarily focus on the GMA\u27s procedural and substantive requirements for adoption of Plans and how these mandates have changed the face of land use planning in Washington State

Natural Language Explanations For Unfulfilled Queries

User requests cannot sometimes be fulfilled by a virtual assistant. In such cases, the virtual assistant typically informs the user that the question cannot be answered or the command cannot be performed, without providing an explanation of the reason for the failure to fulfill the user’s request. This disclosure describes techniques that enable a virtual assistant to provide the user a helpful explanation of why a particular request was not fulfilled. Further, the virtual assistant response can include information on how the user’s query was understood

Characteristics of fetal heart rate tracings prior to uterine rupture

Objective: To identify the fetal heart rate patterns that occurred in a 2‐h period of time preceding uterine rupture. Methods: The fetal monitor strips and the medical records of patients with a confirmed diagnosis of uterine rupture were reviewed. These patients delivered at the University of Michigan Hospital from January 1, 1985 to December 31, 1999 and were ≥28 weeks gestational age. Asymptomatic uterine scar dehiscences were excluded. The weeks of gestation, the number of cesarean sections, the surgical findings, and the maternal complications were obtained from the review of the maternal records. The fetal monitor strips for the 2 h preceding the uterine rupture were analyzed, and the fetal heart rate patterns were classified. Results: During the study period, there were 11 patients identified with uterine rupture. Seven of the 11 (64%) had operative or post‐operative complications. There were no maternal deaths. Review of the eight fetal heart rate tracings available revealed 7/8 (87.5%) with recurrent late decelerations and 4/8 (50%) with terminal bradycardia. All four of the patients with fetal bradycardia were preceded by recurrent late decelerations (100%). Conclusions: The most common fetal heart rate abnormalities that occurred prior to uterine rupture were recurrent late decelerations and bradycardia. The appearance of recurrent late decelerations may be an early sign of impending uterine rupture.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135337/1/ijgo235.pd

Myasthenia gravis and pregnancy: clinical implications and neonatal outcome

BACKGROUND: The myasthenia gravis is twice as common in women as in men and frequently affects young women in the second and third decades of life, overlapping with the childbearing years. Generally, during pregnancy in one third of patients the disease exacerbates, whereas in two thirds it remains clinically unchanged. Complete remission can occur in some patients. METHODS: To describe the clinical course, delivery and neonatal outcome of 18 pregnant women with the diagnosis of myasthenia gravis. Retrospective chart review of pregnant patients with myasthenia gravis, followed at the National Institute of Perinatology in Mexico City over an 8-year period. Data was abstracted from the medical records on the clinical course during pregnancy, delivery and neonatal outcome. RESULTS: From January 1, 1996 to December 31, 2003 18 patients with myasthenia gravis were identified and included in the study. The mean ± SD maternal age was 27.4 ± 4.0 years. During pregnancy 2 women (11%) had an improvement in the clinical symptoms of myasthenia gravis, 7 women (39%) had clinical worsening of the condition of 9 other patients (50%) remained clinically unchanged. Nine patients delivered vaginally, 8 delivered by cesarean section and 1 pregnancy ended in fetal loss. Seventeen infants were born at mean ± SD gestational age of 37.5 ± 3.0 weeks and a mean birth weight of 2710 ± 73 g. Only one infant presented with transient neonatal myasthenia gravis. No congenital anomalies were identified in any of the newborns. CONCLUSIONS: The clinical course of myasthenia gravis during pregnancy is variable, with a significant proportion of patients experiencing worsening of the clinical symptoms. However, neonatal transient myasthenia was uncommon in our patient population