Engaging Patients in Health System Transformation: The experience of the Maine Health Access Foundation\u27s (MeHAF) Advancing Payment Reform Initiative

In 2001, the Institute of Medicine (IOM) identified patient centeredness as one of six essential aims of “a new health care system for the 21st century”.1 Since that time, we have begun a gradual shift from a professionally driven system toward one that is more “patient centered” or “consumer centered,” recognizing and incorporating patients’ perspectives in decisions in clinical care, delivery system, and policies. As the health care system responds to new payment approaches and positions itself to achieve the Triple Aim (i.e. better care, lower cost, enhanced patient experience), it is important to assess how organizations that are moving to advance health care service delivery and payment reform are integrating patient engagement into the health system transformation process. Since 2011, the Maine Health Access Foundation’s Advancing Payment Reform initiative has funded 13 health system transformation projects. Diverse in their approach, each has undertaken efforts to achieve greater patient engagement ranging from involving patients and families as informed and active participants in their own health care (e.g. shared decision making, self-management) to involving patients at the organizational or policy-level through consumer advisory boards and other means to provide guidance for health system transformation. This brief summarizes the experience of these grantees in developing and implementing strategies to engage patients in payment reform and delivery system redesign.2 The purpose is to identify common themes and lessons within and across these initiatives to inform future patient engagement efforts

The Role of Organizational Change in Health System and Payment Reform

The Maine Health Access Foundation (MeHAF) has awarded grants to 14 Maine health organizations to date to mitigate the increasing cost of health care in Maine through innovative delivery system and payment reform strategies that preserve access, improve quality, and offer better value. As part of the evaluation of this initiative, the University of Southern Maine Muskie School of Public Service (Muskie School) is producing a series of issue briefs that capture common themes and challenges across grantees in achieving payment reform and health system delivery change to assess lessons learned. This is the first issue brief which describes our evaluation approach and presents an analysis of the role of organizational change among grantees engaged in delivery system and payment reform

Health Data and Financing and Delivery System Reform: Is the Glass Half Full or Half Empty?

In 2011, the Maine Health Access Foundation (MeHAF) launched its Advancing Payment Reform initiative to stimulate innovative payment and delivery system reform strategies in Maine. This policy paper reports on the health data experience of the 14 program grantees, using interviews conducted in 2013-14 and other information garnered from the evaluation of the initiative. The paper focuses on the role and impact of health data in supporting implementation and monitoring of specific components of the projects’ reform strategies; the data infrastructure challenges the projects have faced and how those have been addressed; and the generalizable lessons learned so far for improving data usefulness, access, analysis, and integration to support payment and delivery system reform. Support for this policy paper was provided by the Maine Health Access Foundation

Encouraging Rural Health Clinics to Provide Mental Health Services: What are the options?

Key Findings: Approximately 6% of independent and 2% of provider-based RHCs offer mental health services. 38% of study RHCs reported their mental health services were not profitable but continued to provide them in response to community and patient needs. An important factor in the development of RHC mental health services is the presence of a local champion who spearheads the development effort

The Provision of Mental Health Services by Rural Health Clinics

The number of Rural Health Clinics (RHCs) providing specialty mental health services remains limited. This study examined changes in the delivery of mental health services by RHCs, their operational characteristics, barriers to the development of services, and policy options to encourage more RHCs to deliver mental health services. Key Findings: Approximately 6% of independent and 2% of provider-based RHCs offer mental health services by doctoral-level psychologists and/or clinical social workers. Models used to provide mental health services include contracted and/or employed clinicians housed in the same facility as primary care providers. A key element in the development of mental health services is the presence of an internal champion (typically clinicians or senior administrators) who identify the need for and undertake implementation of services, help overcome internal barriers, and direct resources to the development of services

Does Lack of Multinutrient Supplementation During Early Pregnancy Increase Vulnerability to Alcohol-Related Preterm or Small-for-Gestational-Age Births?

The objective of this study was to assess whether women who do not take multinutrient supplements during early pregnancy are more susceptible to the effects of low-to-moderate alcohol consumption on preterm birth and small-for-gestational-age birth (SGA) compared to women who do take multinutrients. This analysis included 800 singleton live births to mothers from a cohort of pregnant women recruited for a population-based cohort study conducted in the Kaiser Permanente Medical Care Program in Northern California. Participants were recruited in their first trimester of pregnancy and information about their alcohol use and supplement intake during pregnancy was collected. Preterm birth (n = 53, 7%) was defined as a delivery prior to 37 completed weeks of gestation and SGA birth (n = 124, 16%) was defined as birth weight less than the 10th percentile for the infant’s gestational age and sex compared to US singleton live births. A twofold increase in the odds of SGA birth attributed to low-to-moderate alcohol intake was found among multinutrient supplement non-users (95% CI: 1.1, 5.3). Yet, among multinutrient supplement users, there was no increased risk of an SGA birth for women who drank low-to-moderately compared to women who abstained (aOR: 0.97, 95% CI: 0.6, 1.6). Similar results emerged for preterm birth. Our findings provide marginal evidence that multinutrient supplementation during early pregnancy may modify the risk of SGA births and preterm birth associated with alcohol consumption during pregnancy and may have important implications for pregnant women and women of child-bearing age. However, future research needs to be conducted

Intraspecific Inversions Pose a Challenge for the trnH-psbA Plant DNA Barcode

BACKGROUND: The chloroplast trnH-psbA spacer region has been proposed as a prime candidate for use in DNA barcoding of plants because of its high substitution rate. However, frequent inversions associated with palindromic sequences within this region have been found in multiple lineages of Angiosperms and may complicate its use as a barcode, especially if they occur within species. METHODOLOGY/PRINCIPAL FINDINGS: Here, we evaluate the implications of intraspecific inversions in the trnH-psbA region for DNA barcoding efforts. We report polymorphic inversions within six species of Gentianaceae, all narrowly circumscribed morphologically: Gentiana algida, Gentiana fremontii, Gentianopsis crinita, Gentianopsis thermalis, Gentianopsis macrantha and Frasera speciosa. We analyze these sequences together with those from 15 other species of Gentianaceae and show that typical simple methods of sequence alignment can lead to misassignment of conspecifics and incorrect assessment of relationships. CONCLUSIONS/SIGNIFICANCE: Frequent inversions in the trnH-psbA region, if not recognized and aligned appropriately, may lead to large overestimates of the number of substitution events separating closely related lineages and to uniting more distantly related taxa that share the same form of the inversion. Thus, alignment of the trnH-psbA spacer region will need careful attention if it is used as a marker for DNA barcoding

International Society of Sports Nutrition Position Stand: Probiotics.

Position statement: The International Society of Sports Nutrition (ISSN) provides an objective and critical review of the mechanisms and use of probiotic supplementation to optimize the health, performance, and recovery of athletes. Based on the current available literature, the conclusions of the ISSN are as follows: 1)Probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host (FAO/WHO).2)Probiotic administration has been linked to a multitude of health benefits, with gut and immune health being the most researched applications.3)Despite the existence of shared, core mechanisms for probiotic function, health benefits of probiotics are strain- and dose-dependent.4)Athletes have varying gut microbiota compositions that appear to reflect the activity level of the host in comparison to sedentary people, with the differences linked primarily to the volume of exercise and amount of protein consumption. Whether differences in gut microbiota composition affect probiotic efficacy is unknown.5)The main function of the gut is to digest food and absorb nutrients. In athletic populations, certain probiotics strains can increase absorption of key nutrients such as amino acids from protein, and affect the pharmacology and physiological properties of multiple food components.6)Immune depression in athletes worsens with excessive training load, psychological stress, disturbed sleep, and environmental extremes, all of which can contribute to an increased risk of respiratory tract infections. In certain situations, including exposure to crowds, foreign travel and poor hygiene at home, and training or competition venues, athletes' exposure to pathogens may be elevated leading to increased rates of infections. Approximately 70% of the immune system is located in the gut and probiotic supplementation has been shown to promote a healthy immune response. In an athletic population, specific probiotic strains can reduce the number of episodes, severity and duration of upper respiratory tract infections.7)Intense, prolonged exercise, especially in the heat, has been shown to increase gut permeability which potentially can result in systemic toxemia. Specific probiotic strains can improve the integrity of the gut-barrier function in athletes.8)Administration of selected anti-inflammatory probiotic strains have been linked to improved recovery from muscle-damaging exercise.9)The minimal effective dose and method of administration (potency per serving, single vs. split dose, delivery form) of a specific probiotic strain depends on validation studies for this particular strain. Products that contain probiotics must include the genus, species, and strain of each live microorganism on its label as well as the total estimated quantity of each probiotic strain at the end of the product's shelf life, as measured by colony forming units (CFU) or live cells.10)Preclinical and early human research has shown potential probiotic benefits relevant to an athletic population that include improved body composition and lean body mass, normalizing age-related declines in testosterone levels, reductions in cortisol levels indicating improved responses to a physical or mental stressor, reduction of exercise-induced lactate, and increased neurotransmitter synthesis, cognition and mood. However, these potential benefits require validation in more rigorous human studies and in an athletic population

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

Background Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. Methods We used data from 1990 to 2019 on people aged 30–79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. Findings The number of people aged 30–79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306–359) million women and 317 (292–344) million men in 1990 to 626 (584–668) million women and 652 (604–698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55–62) of women and 49% (46–52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43–51) of women and 38% (35–41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20–27) for women and 18% (16–21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. Interpretation Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings